Nokea
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.
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The nurse is caring for a patient who has burns over 30% of the body surface. Which of the following events indicates that the patient has moved from the emergent to the acute phase of the burn injury?
- A. White blood cell levels decrease.
- B. Blisters and edema have subsided
- C. The patient has large quantities of pale urine.
- D. The patient has been hospitalized for 48 hours.
Correct Answer: C
Rationale: At the end of the emergent phase, capillary permeability normalizes and the patient begins to diurese large amounts of urine with a low specific gravity. Although this may occur at about 48 hours, it may be longer in some patients. Blisters and edema begin to resolve, but this process requires more time. White blood cells may increase or decrease, based on the patient's immune status and any infectious processes.
The nurse is estimating the extent of a burn using the rule of nines for a patient who has been admitted with deep partial-thickness burns of the posterior trunk and right arm. What percentage of the patient's total body surface area (TBSA) has been injured?
Correct Answer: 27
Rationale: When using the rule of nines, the posterior trunk is considered to cover 18% of the patient's body and each arm is 9%. Thus, 18% + 9% = 27% TBSA.
The nurse is caring for a patient who has incurred extensive burn injuries 5 days ago and has been prescribed ranitidine. Which of the following assessments should the nurse use to evaluate the effectiveness of the medication?
- A. Bowel sounds
- B. Stool frequency
- C. Abdominal distention
- D. Stools for occult blood
Correct Answer: D
Rationale: H2 blockers are given to prevent Curling's ulcer in the patient who has suffered burn injuries. H2 blockers do not impact bowel sounds, stool frequency, or appetite.
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 caring for a patient with severe burns who is receiving crystalloid fluid replacement IV. ordered using the Parkland formula. The initial volume of fluid to be administered in the first 24 hours is 30000 ml. The initial rate of administration is 1875 ml/hour. Which of the following infusion rates is accurate after the first 8 hours?
- A. 350 ml/hour
- B. 253 ml/hour
- C. 938 ml/hour
- D. 250 ml/hour
Correct Answer: C
Rationale: Half of the fluid replacement using the Parkland formula is administered in the first 8 hours and the other half over the next 16 hours (25% per each 8 hour period, respectively). In this case, the patient should receive half of the initial rate, or 938 ml/hour.