Nokea
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.
You may also like to solve these questions
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 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 notes a bright red skin colour for a patient who was found unconscious from smoke inhalation in a burning house. Which of the following actions should the nurse take first?
- A. Insert two large-bore IV lines.
- B. Check the patient's orientation.
- C. Place the patient on 100% oxygen using a non-rebreather mask.
- D. Assess for singed nasal hair and dark oral mucous membranes.
Correct Answer: C
Rationale: The patient's history and skin colour suggest carbon monoxide poisoning, which should be treated by rapidly starting oxygen at 100%. The other actions can be taken after the actions to correct gas exchange.
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.