Nokea
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.
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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 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.
Which of the following actions should be included in the plan of care for a patient who has burns of the ears, head, neck, and right arm and hand?
- A. Place the right arm and hand flexed in a position of comfort.
- B. Elevate the right arm and hand on pillows and extend the fingers.
- C. Assist the patient to a supine position with a small pillow under the head.
- D. Position the patient in a side-lying position with rolled towel under the neck.
Correct Answer: B
Rationale: The right hand and arm should be elevated to reduce swelling and the fingers extended to avoid flexion contractures (even though this position may not be comfortable for the patient). The patient with burns of the ears should not use a pillow since this will put pressure on the ears and may stick to the ears. Patients with neck burns should not use a pillow, since the head should be maintained in an extended position in order to avoid contractures.
The nurse is caring for a patient who has circumferential burns of both arms and develops a decrease in radial pulse strength and numbness in the fingers. Which of the following actions should the nurse take?
- A. Notify the health care provider.
- B. Monitor the pulses every 2 hours.
- C. Elevate both arms above heart level with pillows.
- D. Encourage the patient to flex and extend the fingers.
Correct Answer: A
Rationale: The decrease in pulse in a patient with circumferential burns indicates decreased circulation to the arms and the need for escharotomy. Monitoring the pulses is not an adequate response to the decrease in circulation. Elevating the hands or increasing hand movement will not improve the patient's circulation.
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.