Nokea
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.
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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.
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 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.
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.
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.