Nokea
What is the last intervention for a hospitalized severely burned victim during the emergent phase?
- A. Tetanus prophylaxis.
- B. Insert Foley catheter.
- C. Insert nasogastric tube.
- D. Establish airway.
- E. Administer analgesics.
- F. Initiate fluid therapy.
Correct Answer: A,
Rationale: The priority of care should proceed from the establishment of an airway,initiation of fluid therapy,insertion of Foley and NG tube administration of analgesics and tetanus prophylaxis."
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A patient who has sustained a burn injury will undergo wound debridement. The nurse includes which explanation when explaining the purpose of burn wound debridement?
- A. To increase the effectiveness of the skin graft.
- B. Prevention of infection and promote healing.
- C. Promoting suppuration of the wound.
- D. Promoting movement in the affected area.
Correct Answer: B
Rationale: Débridement is the removal of damaged tissue and cellular debris from a wound or burn to prevent infection and to promote healing. Debridement does not increase the effectiveness of the skin graft, promote wound suppuration or movement.
A patient has sustained a burn injury following a house fire. Which finding indicates the need to observe the patient for airway complications?
- A. Bradypnea
- B. Singed nasal hairs
- C. Burns to the upper arms
- D. Intercostal retractions
- E. Grunting noted with respiration
Correct Answer: B,D,E
Rationale: A patient who has sustained a burn injury should be monitored for airway complications if the patient has singed nasal hairs, intercostal retractions or grunting respirations. Tachypnea, not bradypnea, is a finding suggestive of potential airway complications. A patient with burns to the face, neck and upper chest requires further observation.
A patient developed a severe contact dermatitis of the hands, arms, and lower legs after spending an afternoon picking strawberries. The patient states that the itching is severe and cannot keep from scratching. Which instruction will be helpful in managing the pruritus?
- A. Use cool, wet dressings and baths to promote vasoconstriction.
- B. Trim the fingernails short to prevent skin damage from scratching.
- C. Expose the areas to the sun to promote drying and healing of the lesions.
- D. Wear cotton gloves and cover all other affected areas with clothing to prevent environmental irritation.
Correct Answer: A
Rationale: Wet dressings and using Burow's solution help promote the healing process. Cold compresses may be applied to decrease circulation to the area (vasoconstriction). Short nails prevent skin damage, but not pruritus. Exposing the areas to the sun will not manage pruritus. Wearing cotton gloves may prevent environmental irritation, but will not help the existing pruritis.
The nurse is caring for a 26-year-old patient who was burned 72 hours ago. The patient has partial-thickness burns to 24% of the body surface area and begins to excrete large amounts of urine. Which action should the nurse take?
- A. Increase the IV rate and monitor for burn shock.
- B. Monitor for signs of seizure activity.
- C. Assess for signs of fluid overload.
- D. Raise the foot of the bed and apply blankets.
Correct Answer: C
Rationale: As the blood volume increases, the cardiac output increases to increase renal perfusion. The result includes diuresis. However, a great risk for the patient includes fluid overload because of the rapid movement of fluid back into the intravascular space. Burn shock occurs from hypovolemia in the first 72 hours of a burn injury. Seizures are not associated with the burn injury. Raising the foot of the bed would not be of value in this situation.
Which patient instruction will the nurse reinforce relative to the management of systemic lupus erythematosus (SLE)?
- A. Maintain a balance between rest and activity.
- B. Increase activity to promote mobility.
- C. Increase exposure to the sun to increase vitamin D absorption.
- D. Increase sodium consumption.
Correct Answer: A
Rationale: Balanced rest, activity, and diet will support medication management. It is not necessary to increase activity to promote mobility. Limited sunlight exposure is recommended to prevent photosensitivity. SLE often has kidney involvement, which would require reduction of sodium.