Nokea
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.
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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.
The nurse is caring for a patient who has just been admitted with a 40% total body surface area (TBSA) burn injury. Which of the following interventions should the nurse include in the plan of care to maintain adequate nutrition?
- A. Insert a feeding tube and initiate enteral feedings.
- B. Infuse total parenteral nutrition via a central catheter.
- C. Encourage an oral intake of at least 5000 kcal/day
- D. Administer multiple vitamins and minerals in the IV solution.
Correct Answer: A
Rationale: Enteral feedings can usually be initiated during the emergent phase at low rates and increased over 24-48 hours to the goal rate. During the emergent phase, the patient will be unable to eat enough calories to meet nutritional needs and may have a paralytic ileus that prevents adequate nutrient absorption. Vitamins and minerals may be administered during the emergent phase, but these will not assist in meeting the patient's caloric needs. Parenteral nutrition increases the infection risk, does not help preserve gastrointestinal function, and is not routinely used in burn patients.
The nurse is admitting a patient with burns over 30% of total body surface area (TBSA) and who weighs 70 kg. Using the Parkland formula, calculate the volume of lactated Ringer's solution that the nursing staff will administer during the first 24 hours.
Correct Answer: 8400
Rationale: The Parkland formula states that patients should receive 4 mL/kg/% TBSA burned during the first 24 hours. For a 70 kg patient with 30% TBSA burns: 4 mL x 70 kg x 30 = 8400 mL.
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 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.