Chapter 24

Which patient should the nurse assess first?

A patient with smoke inhalation who has wheezes and altered mental status

A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take first?

Notify the health care provider.

A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first?

Place on heart monitor.

A patient who was found unconscious in a burning house is brought to the emergency department by ambulance. The nurse notes that the patient's skin color is bright red. Which action should the nurse take first?

Place the patient on 100% O2using a nonrebreather mask.

An employee spills industrial acids on both arms and legs at work. What action should the occupational health nurse take first?

Remove nonadherent clothing and wristwatch.

The nurse is reviewing laboratory results on a patient who had a large burn 48 hours ago. Which result requires priority action by the nurse?

Serum potassium of 6.1 mEq/L

Which nursing action is a priority for a patient who has suffered a burn injury while working on an electrical power line?

Stabilize the cervical spine.

Esomeprazole (Nexium) is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which nursing assessment would best evaluate the effectiveness of the drug?

Stool occult blood

A patient with burns covering 40% total body surface area (TBSA) is in the acute phase of burn treatment. Which snack would be best for the nurse to offer to this patient?

Vanilla milkshake

Which prescribed drug is best for the nurse to give before scheduled wound debridement on a patient with partial-thickness burns?

hydromorphone (Dilaudid)

A patient has just arrived in the emergency department after an electrical burn from exposure to a high-voltage current. What is the priority nursing assessment?

Extremity movement

Which patient is most appropriate for the burn unit charge nurse to assign to a registered nurse (RN) who has floated from the hospital medical unit?

A patient who has a weight loss of 15% from admission and will have enteral feedings started

The charge nurse observes the following actions being taken by a new nurse on the burn unit. Which action by the new nurse would require immediate intervention by the charge nurse?

The new nurse uses clean gloves when applying antibacterial cream to a burn wound.

A young adult patient who is in the rehabilitation phase 6 months after a severe face and neck burn tells the nurse, "I'm sorry that I'm still alive. My life will never be normal again." Which response by the nurse is best?

"It's true that your life may be different. What concerns you the most?"

A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take?

Notify the health care provider and prepare for endotracheal intubation.

The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine output has dramatically increased. Which action by the nurse would best support maintaining kidney function?

Continue to measure the urine output.

A young adult patient who is in the rehabilitation phase after having deep partial-thickness face and neck burns has a nursing diagnosis of disturbed body image. Which statement by the patient best indicates that the problem is resolving?

Do you think dark beige makeup will cover this scar?"

A nurse is caring for a patient who has burns of the ears, head, neck, and right arm and hand.The nurse should place the patient in which position?

Elevate the right arm and hand on pillows and extend the fingers.

When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes dry, pale, and hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth?

Full-thickness skin destruction

In which order will the nurse take these actions when doing a dressing change for a partial-thickness burn wound on a patient's chest?

Give IV fentanyl (Sublimaze). Clean wound with saline-soaked gauze .Apply silver sulfadiazine cream Apply sterile gauze dressing. Document wound appearance.

On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which of the following prescribed actions should be the nurse's priority?

Increasing the rate of the ordered IV solution.

A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain adequate nutrition, the nurse should plan to take which action?

Insert a feeding tube and initiate enteral feedings.

During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion?

Measure hourly urine output.

Eight hours after a thermal burn covering 50% of a patient's total body surface area (TBSA),the nurse assesses the patient. The patient weighs 92 kg (202.4 lb). Which information would be a priority to communicate to the health care provider?

Urine output of 41 mL over past 2 hours.

A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital. Which action should the nurse take first?

Use pulse oximetry to check oxygen saturation.

While the patient's full-thickness burn wounds to the face are exposed, what nursing action prevents cross contamination?

Wear gown, cap, mask, and gloves during care.

A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be administered in the first 24 hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids?

938 mL/hr

Which action will the nurse include in the plan of care for a patient in the rehabilitation phase after a burn injury to the right arm and chest?

Apply water-based cream to burned areas frequently.

A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first?

Auscultate the patient's lung sounds.