Nokea
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.
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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.
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 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 partial-thickness burns. Which of the following prescribed medications will be best for the nurse to use before wound debridement?
- A. Ketorolac
- B. Lorazepam
- C. Gabapentin
- D. Hydromorphone
Correct Answer: D
Rationale: Opioid pain medications are the best choice for pain control. The other medications are used as adjuvants to enhance the effect of opioids.
Which of the following frequencies of multiple-dressing method burn treatment dressing changes should the nurse should question?
- A. Every 6 hours
- B. Every 12 hours
- C. Once a day
- D. Once a week
Correct Answer: A
Rationale: These dressings are changed at various intervals, from every 12 to 24 hours to once every 14 days, depending on the product. However, the dressing should not be changed 6 hours from application.