Nokea
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.
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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 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.
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 caring for a patient who has burns over 30% of the body surface. Which of the following events indicates that the patient has moved from the emergent to the acute phase of the burn injury?
- A. White blood cell levels decrease.
- B. Blisters and edema have subsided
- C. The patient has large quantities of pale urine.
- D. The patient has been hospitalized for 48 hours.
Correct Answer: C
Rationale: At the end of the emergent phase, capillary permeability normalizes and the patient begins to diurese large amounts of urine with a low specific gravity. Although this may occur at about 48 hours, it may be longer in some patients. Blisters and edema begin to resolve, but this process requires more time. White blood cells may increase or decrease, based on the patient's immune status and any infectious processes.
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.