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What is one clinical manifestation the nurse would expect to find
during the emergent phase in a patient with a full-thickness burn over
the lower half of the body?
a. Fever
b. Shivering
c. Severe pain
d. Unconsciousness - ANSWER -b.
Shivering often occurs in a patient with a burn as a result of chilling
that is caused by heat loss, anxiety, or pain. Severe pain is not
common in full-thickness burns, nor is unconsciousness unless other
factors are present. Fever is a sign of infection in later burn phases.
A patient has a 20% TBSA deep partial-thickness and full-thickness
burn to the right anterior chest and entire right arm. What is important
for a nurse to assess in this patient?
a. Presence of pain
b. Swelling of the arm
c. Formation of eschar
d. Presence of pulses in the arms - ANSWER -d.
In circumferential burns, circulation to the extremities can be severely
impaired and pulses should be monitored closely for signs of
obstruction by edema. Swelling of the arms would be expected but it
becomes dangerous when it occludes blood vessels. Pain and eschar
are also expected.
,Which burn patient should have nasotracheal or endotracheal
intubation?
a. Carbon monoxide poisoning
b. Electrical burns causing cardiac dysrhythmias
c. Thermal burn injuries to the face, neck, or airway
d. Respiratory distress from eschar formation around the chest -
ANSWER -c.
Patients with major injuries involving burns to the face and neck
require intubation within 1 to 2 hours after burn injury to prevent the
need for emergency tracheostomy, which is done if symptoms of
upper respiratory obstruction occur. Carbon monoxide poisoning is
treated with 100% oxygen and eschar constriction of the chest is
treated with an escharotomy.
A patient's deep partial-thickness burns are treated with the open
method. What should the nurse do when caring for the patient?
a. Ensure that sterile water is used in the debridement tank.
b. Wear a cap, mask, gown, and gloves during patient contact.
c. Use sterile gloves to remove the dressings and wash the wounds.
d. Apply topical antimicrobial ointment with clean gloves to prevent
wound trauma. - ANSWER -b.
When the patient's wounds are exposed with the open method, the
staff must wear caps, masks, gowns, and gloves. Sterile water is not
necessary in the debridement tank and topical antiinfective agents
should be applied with sterile gloves. If some dressings are used with
the open method, they are removed and wounds are washed with
clean gloves.
, A patient with deep partial-thickness burns over 45% of his trunk and
legs is going for debridement in the cart shower 48 hours post burn.
What is the drug of choice to control the patient's pain during this
activity?
a. IV morphine
b. Midazolam (Versed)
c. IM meperidine (Demerol)
d. Long-acting oral morphine - ANSWER -a.
Morphine is the drug of choice for pain control and during the
emergent phase it should be administered IV because GI function is
impaired and IM injections will not be absorbed adequately.
The nurse assesses that bowel sounds are absent and abdominal
distention is present in a patient 12 hours post burn. The nurse
notifies the health care provider and anticipates doing what action?
a. Withhold all oral intake except water
b. Insert a nasogastric tube for decompression
c. Administer a H2-histamine blocker such as cimetidine (Tagamet)
d. Administer nutritional supplements through a feeding tube placed
in the duodenum - ANSWER -b.
The patient with large burns often develops paralytic ileus within a
few hours and a nasogastric tube is inserted and connected to low,
intermittent suction. After GI function returns, feeding tubes may be
used for nutritional supplementation and H2 histamine blockers may
be used to prevent Curling's ulcers. Free water is not given to drink
because of the potential for water intoxication.
How should the nurse position the patient with ear, face, and neck
burns?
a. Prone