Nokea
The nurse is caring for a patient who has burns over 30% of the body surface. Which of the following events indicates that the patient has moved from the emergent to the acute phase of the burn injury?
- A. White blood cell levels decrease.
- B. Blisters and edema have subsided
- C. The patient has large quantities of pale urine.
- D. The patient has been hospitalized for 48 hours.
Correct Answer: C
Rationale: At the end of the emergent phase, capillary permeability normalizes and the patient begins to diurese large amounts of urine with a low specific gravity. Although this may occur at about 48 hours, it may be longer in some patients. Blisters and edema begin to resolve, but this process requires more time. White blood cells may increase or decrease, based on the patient's immune status and any infectious processes.
You may also like to solve these questions
In which order should the nurse take these actions when doing a dressing change for a partial-thickness burn wound on a patient's back?
- A. Apply sterile gauze dressing.
- B. Document wound appearance.
- C. Apply silver sulphadiazine cream.
- D. Administer IV fentanyl.
- E. Clean wound with saline-soaked gauze.
Correct Answer: D,E,C,A,B
Rationale: Since partial-thickness burns are very painful, the nurse's first action should be to administer pain medications. The wound will then be cleaned, antibacterial cream applied, and covered with a new sterile dressing. The last action should be to document the appearance of the wound.
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 is in the emergent phase of burn care. Which of the following nursing actions will be most useful in determining whether the patient is receiving adequate fluid infusion?
- A. Check skin turgor.
- B. Monitor daily weight.
- C. Assess mucous membranes.
- D. Measure hourly urine output.
Correct Answer: D
Rationale: When fluid intake is adequate, the urine output will be at least 0.5-1 ml/kg/hour. The patient's weight is not useful in this situation because of the effects of third spacing and evaporative fluid loss. Mucous membrane assessment and skin turgor also may be used, but they are not as adequate in determining that fluid infusions are maintaining adequate perfusion.
After receiving change-of-shift report, which of the following patients should the nurse assess first?
- A. A patient with 40% total body surface area (TBSA) burns who is receiving IV fluids at 500 mL/hour
- B. A patient with smoke inhalation who has wheezes and altered mental status
- C. A patient with full-thickness leg burns who has a dressing change scheduled
- D. A patient with abdominal burns who is complaining of level 8 (0-10 scale) pain
Correct Answer: B
Rationale: This patient has evidence of lower airway injury and hypoxemia and should be assessed immediately to determine need for oxygen or intubation. The other patients also should be assessed as rapidly as possible, but they do not have evidence of life-threatening complications.
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.