Flashcards in Chapter 55 Deck (22):
The nurse is at the scene of a fire caring for a patient with a thermal burn on the face, chest, and abdomen. What action should the nurse perform first?
Ensure an open airway.
The nurse is caring for a patient with burns covering the entire surface of both arms and the anterior trunk. Approximately what percentage of the patient’s body surface area has been affected?
The nurse is caring for a patient in the initial phase of treatment for a partial-thickness burn. The patient has been stabilized, with blood pressure 140/88 mm Hg, pulse 78 beats/min, respirations 22 breaths/min, and temperature 97.4°F (36.3°C). Which new assessment finding should be immediately communicated to the health care provider (HCP)?
The nurse is caring for a patient who is 2 days post-inhalation burn injury from a house fire. Which outcome best indicates that nursing interventions for impaired gas exchange have been effective?
The patient is alert and oriented
A patient is having a surgical procedure done to promote peripheral tissue perfusion in an extremity with full-thickness circumferential burns. What term should the nurse use to document this procedure?
The nurse is caring for a patient who is receiving fluid replacement after being burned on 37% of the body. Nursing assessment reveals a blood pressure of 80/60 mm Hg, heart rate of 120 beats/min, and urine output of 10 mL over the past hour. After reporting these findings, which order should the nurse expect to be prescribed for this patient?
Increase IV fluid
The nurse is providing wound care to a patient’s skin graft donor sites used for burn treatment. For which type of wound is this nurse providing care?
The nurse is caring for a patient admitted to the burn unit with burns to 45% of the body. After 3 days, the nurse notes that the patient’s temperature is newly elevated at 100.2°F (37.9°C), and the patient exhibits new-onset agitation and confusion. What should the nurse do first?
A patient is admitted to the emergency department with chemical burns to the chest and abdomen. The RN immediately begins a sterile saline lavage. What should the licensed practical nurse (LPN) do to assist during this procedure?
Remove patient clothing
The nurse is caring for a patient 3 days following a split-thickness burn injury from a fire. Which observation indicates that nursing interventions to promote cardiac output have been effective?
A patient is diagnosed with superficial partial-thickness burns. How many days should the nurse instruct the patient that these burns will need to heal?
A patient has burns on both legs and in the genital/perineum area. What is this patient’s percentage of burned area?
A patient wants to know how long it will take to know if a skin graft used to cover a burn site is successful. How many days should the nurse explain as needed for graft vascularization to occur?
3 to 5
The nurse notes that a patient with full thickness burns has an increase in hematocrit level. What should the nurse realize is causing this change in laboratory value?
Loss of intravascular fluid
A patient with a deep partial thickness burn is prescribed wet to dry gauze dressings. Which type of debridement is the nurse performing with this dressing?
The nurse is caring for a patient who sustained a partial-thickness burn to the face. Which assessment findings should the nurse expect? (Select all that apply.)
Bright red color
The nurse is assisting with the care of a patient admitted to the emergency department with chemical burns across the chest and hands. Which actions should be included in the plan of care? (Select all that apply.)
Remove all contaminated clothing.
Cover the patient with a clean sheet.
Obtain a history of the event and burning agent.
Provide copious tepid water lavage for 20 minutes.
The nurse is caring for a patient with extensive burns. For which systemic responses to the burn should the nurse monitor the patient? (Select all that apply.)
Increased oxygen consumption
Depression of immunoglobulins
The nurse is preparing a patient with 46% total body surface area burned for graft placement. Which anatomical locations should the nurse expect to have a lower rate of graft success than other areas of the body? (Select all that apply.
A victim of a fire in a manufacturing plant is brought to the emergency department. The HCP suspects this victim has sustained an inhalation injury. Which tests should the nurse expect to be prescribed for this patient? (Select all that apply.)
Arterial blood gases
The nurse is preparing to apply dressings to a patient’s partial-thickness burn wounds. What should the nurse keep in mind when applying these dressings? (Select all that apply.)
Elevate affected extremities.
Limit the amount of dressing bulk.
Wrap extremities from distal to proximal.