Nokea
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.
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Which of the following laboratory results requires the most rapid action by the nurse who is caring for a patient who suffered a large burn 48 hours ago?
- A. Hct 52%
- B. BUN 13.8 mmol/L.
- C. Serum sodium 146 mmol/L.
- D. Serum potassium 6.2 mmol/L.
Correct Answer: D
Rationale: Hyperkalemia can lead to fatal bradycardia and indicates that the patient requires cardiac monitoring and immediate treatment to lower the potassium level. The other laboratory values also are abnormal and require changes in treatment, but they are not as immediately life threatening as the elevated potassium level.
Which of the following snacks will be best for the nurse to offer to a patient with burns covering 40% total body surface area (TBSA) who is in the acute phase of burn treatment?
- A. Strawberry gelatin
- B. Whole wheat bagel
- C. Chunky applesauce
- D. Chocolate milkshake
Correct Answer: D
Rationale: A patient with a burn injury needs high protein and calorie food intake, and the milkshake is the highest in these nutrients. The other choices are not as nutrient-dense as the milkshake.
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 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.
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.