Nokea
The nurse is caring for a patient who has deep partial-thickness and full-thickness burns of the face and chest and is having the wounds treated with the open method. Which of the following nursing actions should be included in the plan of care?
- A. Restritct all visitors to prevent cross-contamination of wounds.
- B. Wear gowns, caps, masks, and gloves during all care of the patient.
- C. Turn the room temperature up to at least 20 C (68 F) during dressing changes.
- D. Administer prophylactic antibiotics to prevent bacterial colonization of wounds.
Correct Answer: B
Rationale: Use of gowns, caps, masks, and gloves during all patient care will decrease the possibility of wound contamination for a patient whose burns are not covered. Restricting all visitors is not necessary and will have adverse psychosocial consequences for the patient. The room temperature should be kept at approximately 30 C (86 F) for patients with open burn wounds. Systemic antibiotics are not well absorbed into deep burns because of the lack of circulation.
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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.
The nurse is caring for a patient who has incurred extensive burn injuries 5 days ago and has been prescribed ranitidine. Which of the following assessments should the nurse use to evaluate the effectiveness of the medication?
- A. Bowel sounds
- B. Stool frequency
- C. Abdominal distention
- D. Stools for occult blood
Correct Answer: D
Rationale: H2 blockers are given to prevent Curling's ulcer in the patient who has suffered burn injuries. H2 blockers do not impact bowel sounds, stool frequency, or appetite.
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 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 be included in the plan of care for a patient who has burns of the ears, head, neck, and right arm and hand?
- A. Place the right arm and hand flexed in a position of comfort.
- B. Elevate the right arm and hand on pillows and extend the fingers.
- C. Assist the patient to a supine position with a small pillow under the head.
- D. Position the patient in a side-lying position with rolled towel under the neck.
Correct Answer: B
Rationale: The right hand and arm should be elevated to reduce swelling and the fingers extended to avoid flexion contractures (even though this position may not be comfortable for the patient). The patient with burns of the ears should not use a pillow since this will put pressure on the ears and may stick to the ears. Patients with neck burns should not use a pillow, since the head should be maintained in an extended position in order to avoid contractures.