Lewis - Chapter 24: Burns
A nurse is caring for a patient who has burns of the ears, head, neck, and proper arm and hand.
The nurse ought to vicinity the affected person wherein position?
A. Place the proper arm and hand flexed in a position of consolation.
B. Elevate the proper arm and hand on pillows and increase the palms.
C. Assist the patient to a supine position with a small pillow under the top.
D. Position the affected person in a facet-mendacity function with rolled towel beneath the neck.
- ANS-ANS: B
The proper hand and arm must be extended to lessen swelling and the hands extended to avoid
flexion contractures (even though this role may not be comfortable for the patient). The affected
person with burns of the ears have to no longer use a pillow for the top because this will
positioned stress at the ears, and the pillow may additionally stick with the ears. Patients with
neck burns have to not use a pillow or rolled towel due to the fact the pinnacle need to be
maintained in an prolonged function with the intention to avoid contractures.
DIF: Cognitive Level: Apply (software)
A affected person arrives within the emergency branch with facial and chest burns because of a
residence fireplace. Which movement ought to the nurse take first?
A. Auscultate the affected person's lung sounds.
B. Determine the extent and intensity of the burns.
C. Give the prescribed hydromorphone (Dilaudid).
D. Infuse the prescribed lactated Ringer's answer. - ANS-ANS: A
A affected person with facial and chest burns is at chance for inhalation harm and assessment
of airway and respiration is the concern. The different movements may be completed after
airway control is assured.
DIF: Cognitive Level: Analyze (analysis)
A affected person has simply arrived within the emergency department after an electrical burn
from exposure to a high-voltage present day. What is the concern nursing assessment?
A. Oral temperature c. Extremity movement
b. Peripheral pulses d. Pupil response to mild - ANS-ANS: C
All patients with electric burns ought to be considered at risk for cervical backbone harm, and
evaluation of extremity motion will offer baseline facts. The other assessment data are also vital
but now not as important as determining the cervical spine status.
DIF: Cognitive Level: Analyze (analysis)
A patient has just been admitted with a forty% general body surface region (TBSA) burn harm.
To preserve good enough nutrients, the nurse ought to plan to take which action?
A. Administer vitamins and minerals intravenously.
B. Insert a feeding tube and initiate enteral feedings.
, C. Infuse overall parenteral nutrition through a valuable catheter.
D. Encourage an oral consumption of at least 5000 kcal consistent with day. - ANS-ANS: B
Enteral feedings can commonly be began during the emergent segment at low prices and
multiplied over 24 to forty eight hours to the intention rate. During the emergent segment, the
affected person will be unable to devour enough energy to satisfy dietary wishes and may have
a paralytic ileus that stops adequate nutrient absorption. Vitamins and minerals may be
administered at some stage in the emergent section, but these will not assist in assembly the
affected person's caloric needs. Parenteral nutrition increases the contamination hazard, does
not assist keep gastrointestinal characteristic, and isn't always routinely used in burn sufferers
unless the gastrointestinal tract is not to be had to be used.
DIF: Cognitive Level: Apply (application)
A patient is admitted to the burn unit with burns to the head, face, and fingers. Initially, wheezes
are heard, however an hour later, the lung sounds are reduced and no wheezes are audible.
What is the excellent action for the nurse to take?
A. Encourage the patient to cough and auscultate the lungs once more.
B. Notify the health care issuer and put together for endotracheal intubation.
C. Document the results and continue to screen the affected person's respiration rate.
D. Reposition the affected person in excessive-Fowler's position and re-examine breath sounds.
- ANS-ANS: B
The affected person's history and scientific manifestations recommend airway edema, and the
health care provider ought to be notified straight away in order that intubation can be carried out
hastily. Placing the affected person in a more upright role or having the patient cough will now
not cope with the trouble of airway edema. Continuing to reveal is inappropriate because instant
action have to arise.
DIF: Cognitive Level: Apply (software)
A patient who has burns on the fingers, legs, and chest from a residence hearth has become
agitated and restless 8 hours after being admitted to the clinic. Which movement have to the
nurse take first?
A. Stay at the bedside and reassure the patient.
B. Administer the ordered morphine sulfate IV.
C. Assess orientation and level of cognizance.
D. Use pulse oximetry to test oxygen saturation. - ANS-ANS: D
Agitation in a patient who can also have suffered inhalation damage may suggest hypoxia, and
this should be assessed by means of the nurse first. Administration of morphine may be
indicated if the nurse determines that the agitation is caused by pain. Assessing degree of
recognition and orientation is also appropriate but now not as vital as figuring out whether the
patient is hypoxemic. Reassurance isn't always beneficial to reduce agitation in a hypoxemic
patient.
DIF: Cognitive Level: Analyze (evaluation)
A nurse is caring for a patient who has burns of the ears, head, neck, and proper arm and hand.
The nurse ought to vicinity the affected person wherein position?
A. Place the proper arm and hand flexed in a position of consolation.
B. Elevate the proper arm and hand on pillows and increase the palms.
C. Assist the patient to a supine position with a small pillow under the top.
D. Position the affected person in a facet-mendacity function with rolled towel beneath the neck.
- ANS-ANS: B
The proper hand and arm must be extended to lessen swelling and the hands extended to avoid
flexion contractures (even though this role may not be comfortable for the patient). The affected
person with burns of the ears have to no longer use a pillow for the top because this will
positioned stress at the ears, and the pillow may additionally stick with the ears. Patients with
neck burns have to not use a pillow or rolled towel due to the fact the pinnacle need to be
maintained in an prolonged function with the intention to avoid contractures.
DIF: Cognitive Level: Apply (software)
A affected person arrives within the emergency branch with facial and chest burns because of a
residence fireplace. Which movement ought to the nurse take first?
A. Auscultate the affected person's lung sounds.
B. Determine the extent and intensity of the burns.
C. Give the prescribed hydromorphone (Dilaudid).
D. Infuse the prescribed lactated Ringer's answer. - ANS-ANS: A
A affected person with facial and chest burns is at chance for inhalation harm and assessment
of airway and respiration is the concern. The different movements may be completed after
airway control is assured.
DIF: Cognitive Level: Analyze (analysis)
A affected person has simply arrived within the emergency department after an electrical burn
from exposure to a high-voltage present day. What is the concern nursing assessment?
A. Oral temperature c. Extremity movement
b. Peripheral pulses d. Pupil response to mild - ANS-ANS: C
All patients with electric burns ought to be considered at risk for cervical backbone harm, and
evaluation of extremity motion will offer baseline facts. The other assessment data are also vital
but now not as important as determining the cervical spine status.
DIF: Cognitive Level: Analyze (analysis)
A patient has just been admitted with a forty% general body surface region (TBSA) burn harm.
To preserve good enough nutrients, the nurse ought to plan to take which action?
A. Administer vitamins and minerals intravenously.
B. Insert a feeding tube and initiate enteral feedings.
, C. Infuse overall parenteral nutrition through a valuable catheter.
D. Encourage an oral consumption of at least 5000 kcal consistent with day. - ANS-ANS: B
Enteral feedings can commonly be began during the emergent segment at low prices and
multiplied over 24 to forty eight hours to the intention rate. During the emergent segment, the
affected person will be unable to devour enough energy to satisfy dietary wishes and may have
a paralytic ileus that stops adequate nutrient absorption. Vitamins and minerals may be
administered at some stage in the emergent section, but these will not assist in assembly the
affected person's caloric needs. Parenteral nutrition increases the contamination hazard, does
not assist keep gastrointestinal characteristic, and isn't always routinely used in burn sufferers
unless the gastrointestinal tract is not to be had to be used.
DIF: Cognitive Level: Apply (application)
A patient is admitted to the burn unit with burns to the head, face, and fingers. Initially, wheezes
are heard, however an hour later, the lung sounds are reduced and no wheezes are audible.
What is the excellent action for the nurse to take?
A. Encourage the patient to cough and auscultate the lungs once more.
B. Notify the health care issuer and put together for endotracheal intubation.
C. Document the results and continue to screen the affected person's respiration rate.
D. Reposition the affected person in excessive-Fowler's position and re-examine breath sounds.
- ANS-ANS: B
The affected person's history and scientific manifestations recommend airway edema, and the
health care provider ought to be notified straight away in order that intubation can be carried out
hastily. Placing the affected person in a more upright role or having the patient cough will now
not cope with the trouble of airway edema. Continuing to reveal is inappropriate because instant
action have to arise.
DIF: Cognitive Level: Apply (software)
A patient who has burns on the fingers, legs, and chest from a residence hearth has become
agitated and restless 8 hours after being admitted to the clinic. Which movement have to the
nurse take first?
A. Stay at the bedside and reassure the patient.
B. Administer the ordered morphine sulfate IV.
C. Assess orientation and level of cognizance.
D. Use pulse oximetry to test oxygen saturation. - ANS-ANS: D
Agitation in a patient who can also have suffered inhalation damage may suggest hypoxia, and
this should be assessed by means of the nurse first. Administration of morphine may be
indicated if the nurse determines that the agitation is caused by pain. Assessing degree of
recognition and orientation is also appropriate but now not as vital as figuring out whether the
patient is hypoxemic. Reassurance isn't always beneficial to reduce agitation in a hypoxemic
patient.
DIF: Cognitive Level: Analyze (evaluation)
