Nokea
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.
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The nurse is admitting a patient with extensive electrical burn injuries. Which of the following prescribed interventions should the nurse implement first?
- A. Start two large bore IVs.
- B. Place on cardiac monitor.
- C. Apply dressings to burned areas.
- D. Assess for pain at contact points.
Correct Answer: B
Rationale: After an electrical burn, the patient is at risk for fatal dysrhythmias and should be placed on a cardiac monitor. The other actions should be accomplished in the following order: Start two IVs, assess for pain, and apply dressings.
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.
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.
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.
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.