Nokea
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.
You may also like to solve these questions
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 caring for a patient who has deep partial-thickness and full-thickness burns of the face and chest and is having the wounds treated with the open method. Which of the following nursing actions should be included in the plan of care?
- A. Restritct all visitors to prevent cross-contamination of wounds.
- B. Wear gowns, caps, masks, and gloves during all care of the patient.
- C. Turn the room temperature up to at least 20 C (68 F) during dressing changes.
- D. Administer prophylactic antibiotics to prevent bacterial colonization of wounds.
Correct Answer: B
Rationale: Use of gowns, caps, masks, and gloves during all patient care will decrease the possibility of wound contamination for a patient whose burns are not covered. Restricting all visitors is not necessary and will have adverse psychosocial consequences for the patient. The room temperature should be kept at approximately 30 C (86 F) for patients with open burn wounds. Systemic antibiotics are not well absorbed into deep burns because of the lack of circulation.
The nurse is admitting a patient to the burn unit who has burns to the upper body and head after a garage fire. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. Which of the following actions should the nurse implement first?
- A. Encourage the patient to cough and ausculate the lungs again.
- B. Notify the health care provider and prepare for endotracheal intubation.
- C. Document the results and continue to monitor the patient's respiratory rate.
- D. Reposition the patient in high-Fowler's position and reassess breath sounds.
Correct Answer: B
Rationale: The patient's history and clinical manifestations suggest airway edema and the health care provider should immediately be notified so that intubation can rapidly be done. Placing the patient in a more upright position or having the patient cough will not address the problem of airway edema. Continuing to monitor is inappropriate because immediate action should occur.
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.
Six hours after a thermal burn covering 50% of a patient's total body surface area (TBSA), the nurse obtains these data when assessing a patient who weighs 55 kg. Which of the following information is priority for the nurse to communicate to the health care provider?
- A. Blood pressure is 94/46 per arterial line.
- B. Serous exudate is leaking from the burns.
- C. Cardiac monitor shows a pulse rate of 104.
- D. Urine output is 20 mL/hour for the past 2 hours.
Correct Answer: D
Rationale: The urine output should be at least 0.5-1.0 mL/kg/hour during the emergent phase, when the patient is at great risk for hypovolemic shock. The nurse should notify the health care provider because a higher IV fluid rate is needed. BP during the emergent phase should be greater than 90 systolic, and the pulse rate should be less than 120. Serous exudate from the burns is expected during the emergent phase.