Burns
which intervention should the ED nurse initiate for a client who has sustained a high-voltage electrical? select all: 1. initiate continuous cardiac monitoring 2. identify entrance and exit wounds 3. give analgesic by mouth as needed 4. keep burned limbs below the level of heart 5. cover burned areas with clean sheets
1,2,5- cover burned areas with dry dressings or a clean sheet...to prevent infection 3. PO pain meds are not as effective in this case 4. keep limbs ABOVE the heart to decrease edema duh!
the nurse suspects carbon monoxide poisoning when the client who was removed from a burning building exhibits which s/s? select all: 1. dizziness 2. epigastric pain 3. excess salivation 4. premature ventricular contractions 5. sweet aromatic odor to breath
1,4- not enough o2 is getting to the vital organs, so dizziness, blurred vision, dull headache, cardiac arrhythmias and respiratory depression can occur 2. not likely 3. not likely 5. not likely
how much fluid does the nurse need to give a client weighing 155 lbs (70 kg) with burns covering 50% of TBSA in the first 24 hours with an order of 4ml/kg/% of NS? (according to american burn association)
14,000 ml in the first 24 hours... 4 ml x 70 kg x 50% = 14,000 ml
what should the nurse assess when examining a client who has had a fasciotomy of the forearm? select all: 1. brachial pulse 2. cap refill 3. color 4. presence of thrill 5. skin turgur
2,3- since cutting arm to relieve pressure check for circulation 1. need to check distal pulses below the fasciotomy...and brachial is in the upper arm idek smh 4. thats for dialysis shunt 5. that checks for hydration.. not for circulatioin
Would you expect a patient with partial thickness burns to 52% of body to have low or high CVP? why?
LOW, bc losing fluids and third spacing so pressure would decrease... CVP less than 2 is likely
using the rule of 9's, determine how much TBSA is burned for a client with partial and full thickness burns over anterior trunk, anterior and posterior aspect of left leg, anterior aspect of right leg, and peritoneal area. (round to whole number)
TBSA burned= 46% anterior trunk= 18 entire left leg= 18 anterior right leg= 9 peritoneal area= 1
what is the nurse's PRIORITY when treating a client with full thickness burns over 30% of body?
establish IV access of NS!... needs fluid resuscitation asap so needs access site right away