Section 25: Nursing Management: Burns
1 . Once assessing a patient who spilled hot petrol on the correct leg and foot, the nurse paperwork that the
pores and skin is dry, pale, hard skin. The patient states which the burn is usually not agonizing. What term would the nurse value to document the burn depth?
a. First-degree skin damage
b. Full-thickness skin devastation
c. Profound partial-thickness epidermis destruction
deb. Superficial partial-thickness skin destruction
With full-thickness skin break down, the appearance is definitely pale and dry or leathery plus the area is painless due to associated neurological destruction. Erythema, swelling, and blisters point out a profound partial-thickness burn off. With succinct, pithy partial-thickness burns up, the area is definitely red, nevertheless no montage are present. Close burns exhibit erythema, blanching, and soreness. DIF: Intellectual Level: Appreciate (comprehension)
BEST: Nursing Procedure: Assessment
MSC: NCLEX: Physical Integrity
2 . On admission to the burn unit, a patient with an approximate 25% body building surface area
(TBSA) burn has got 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 will action will the nurse predict taking right now?
a. Screen urine result every four hours.
b. Still monitor the laboratory effects.
c. Improve the rate in the ordered IV solution.
d. Type and crossmatch to get a blood transfusion.
The patient's laboratory data show hemoconcentration, which may lead to a decrease in blood flow for the microcirculation until fluid intake is increased. Because the hematocrit and hemoglobin are enhanced, a transfusion is inappropriate, although transfusions may be needed after the aufstrebend phase as soon as the patient's substance balance continues to be restored. In admission to a burn unit, the urine output will be monitored more often than just about every 4 hours; likely every1 hour.
DIF: Intellectual Level: Apply (application)
BEST: Nursing Process: Planning
MSC: NCLEX: Physical Integrity
a few. A patient can be admitted to the burn device with burns to the head, face, and hands. Initially,
wheezes are heard, but the hour afterwards, the lung sounds happen to be decreased and no wheezes are audible. What is the best action for the nurse to take?
a. Encourage the patient to cough and auscultate the lungs once again. b. Notify the health attention provider and prepare for endotracheal intubation. c. Document the results and continue to monitor the person's respiratory level. d. Reposition the patient in high-Fowler's location and reflect on breath noises.
The patient's history and clinical manifestations suggest respiratory tract edema as well as the health care provider should be notified right away, so that intubation can be done speedily. Placing the affected person in a more straight position or perhaps having the affected person cough will not address the situation of throat edema. Continuing to keep an eye on is improper because instant action should certainly occur. DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Execution
MSC: NCLEX: Physiological Integrity
4. A patient with extreme burns has crystalloid liquid replacement purchased using the Parkland
formula. Your initial volume of liquid to be given in the initial 24 hours is usually 30, 500 mL. Your initial rate of administration can be 1875 mL/hr. After the 1st 8 hours, what rate should the nurse infuse the IV essential fluids?
a. three hundred and fifty mL/hour
w. 523 mL/hour
c. 938 mL/hour
deb. 1250 mL/hour
Half of the fluid replacement using the Parkland formula is implemented in the initial 8 hours and the partner over the next 16 hours. In this case, the person should receive half the initial charge, or 938 mL/hr.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Setup
MSC: NCLEX: Physiological Ethics
5. Through the emergent period of lose care, which assessment will be most useful in determining...