Nokea
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.
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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 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 estimating the extent of a burn using the rule of nines for a patient who has been admitted with deep partial-thickness burns of the posterior trunk and right arm. What percentage of the patient's total body surface area (TBSA) has been injured?
Correct Answer: 27
Rationale: When using the rule of nines, the posterior trunk is considered to cover 18% of the patient's body and each arm is 9%. Thus, 18% + 9% = 27% TBSA.
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 frequencies of multiple-dressing method burn treatment dressing changes should the nurse should question?
- A. Every 6 hours
- B. Every 12 hours
- C. Once a day
- D. Once a week
Correct Answer: A
Rationale: These dressings are changed at various intervals, from every 12 to 24 hours to once every 14 days, depending on the product. However, the dressing should not be changed 6 hours from application.