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The nurse notes a bright red skin colour for a patient who was found unconscious from smoke inhalation in a burning house. Which of the following actions should the nurse take first?
- A. Insert two large-bore IV lines.
- B. Check the patient's orientation.
- C. Place the patient on 100% oxygen using a non-rebreather mask.
- D. Assess for singed nasal hair and dark oral mucous membranes.
Correct Answer: C
Rationale: The patient's history and skin colour suggest carbon monoxide poisoning, which should be treated by rapidly starting oxygen at 100%. The other actions can be taken after the actions to correct gas exchange.
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After receiving change-of-shift report, which of the following patients should the nurse assess first?
- A. A patient with 40% total body surface area (TBSA) burns who is receiving IV fluids at 500 mL/hour
- B. A patient with smoke inhalation who has wheezes and altered mental status
- C. A patient with full-thickness leg burns who has a dressing change scheduled
- D. A patient with abdominal burns who is complaining of level 8 (0-10 scale) pain
Correct Answer: B
Rationale: This patient has evidence of lower airway injury and hypoxemia and should be assessed immediately to determine need for oxygen or intubation. The other patients also should be assessed as rapidly as possible, but they do not have evidence of life-threatening complications.
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.
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 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 nursing actions should be done first for a patient who has suffered a burn injury while working on an electrical power line?
- A. Obtain the blood pressure.
- B. Stabilize the cervical spine.
- C. Assess for the contact points.
- D. Check alertness and orientation.
Correct Answer: B
Rationale: Cervical spine injuries are commonly associated with electrical burns. Therefore stabilization of the cervical spine takes precedence after airway management. The other actions also are included in the emergent care after electrical burns, but the most important action is to avoid spinal cord injury.