HESI RN Case Study Burns A+

HESI RN Case Study Burns A+ - What is the primary goal of fluid resuscitation in a burn patient? ️️ To restore circulating blood volume and maintain organ perfusion. - Why is the Parkland formula important in burn management? ️️ It provides a guideline for calculating fluid needs in the first 24 hours after a burn. - What is the recommended type of fluid for initial resuscitation in burn patients? ️️ Lactated Ringer's solution. - How should the total fluid calculated by the Parkland formula be administered within the first 24 hours? ️️ Half of the total volume should be administered in the first 8 hours, and the remaining half in the next 16 hours. - What is the most reliable indicator of adequate fluid resuscitation in a burn patient? ️️ Urine output of 0.5-1 mL/kg/hr for adults. - Why are burn patients at risk of hypothermia? ️️ They lose their skin barrier, which helps regulate body temperature. - What is the significance of monitoring peripheral pulses in a burn patient? ️️ To assess for circulatory compromise due to eschar or swelling. - Why is early removal of non-viable tissue important in burn care? ️️ It reduces the risk of infection and promotes healing. - What complication should be monitored for in patients with circumferential burns of the limbs? ️️ Compartment syndrome. - What is the purpose of applying a topical antimicrobial agent to burn wounds? ️️ To prevent infection and reduce bacterial colonization. - Why are burn patients often placed on a high-protein, high-calorie diet? ️️ To support tissue healing and meet increased metabolic demands. - Why is it important to assess airway status in a patient with burns around the face or neck? ️️ These burns may indicate potential airway swelling and risk of obstruction. - What is the purpose of an escharotomy in burn management? ️️ To relieve pressure and restore circulation in areas with constrictive eschar. - Why should intravenous rather than oral pain medications be used in the acute phase of burn care? ️️ Absorption of oral medications may be impaired in burn patients due to decreased gastrointestinal perfusion. - Why is tetanus prophylaxis given to burn patients? ️️ Burns are open wounds that increase the risk of tetanus infection. - How does inhalation injury complicate burn treatment? ️️ It can lead to respiratory distress or failure, requiring oxygen therapy or mechanical ventilation. - What is the role of physical therapy in burn recovery? ️️ To maintain joint mobility and prevent contractures. - Why is psychological support important for burn patients? ️️ To address the emotional and psychological impact of their injuries and promote overall recovery. - How can sepsis be identified early in burn patients? ️️ By monitoring for signs such as fever, increased heart rate, and altered mental status. Which action is included when a Level I disaster is declared? ️️All local hospitals prepare to receive casualties. Which action should the nurse implement to help these family members cope with this tragedy? ️️Designate specific family areas that are staffed with counselors. EMS personnel triage clients, with multiple casualties noted. Which action should the triage nurse implement first? ️️Place a disaster tag securely on each victim. Triage determines in what order a client is seen by a healthcare provider (HCP). Which of the following clients would the nurse identify with a red tag? ️️-A client whose vital signs include respirations at 22 breaths/min , pulse at 120 beats/min, and blood pressure at 85/52 mmHg. -A client with a pulsating femur wound. -A client with full thickness burns over 50% of the body. Which triage category should the nurse assign to James? ️️Priority 1, Color Red. The client has many physical, emotional, and psychosocial needs. Which intervention is most important for the nurse to implement upon admission? ️️Establish and maintain an open airway. The nurse should document which percentage of body surface? ️️45% James grimaces in pain as the nurse assesses James' red and blistered wounds that are affecting his epidermis and dermis. Based on this assessment, which finding best describes the James' burns? ️️Partial thickness or second degree burns. Based on the nurse's understanding of the Parkland Formula, which rate correctly describes the time the fluid is given to the client? ️️The nurse administers the first half of the fluid from the time the burn occurred over 8 hours, and the second half over the following 16 hours. Which action should the nurse take? ️️Inform the officer that he must first speak to James' parents. The police officer then asks to see James' ED medical record. Which action should the nurse take concerning this request? ️️Allow the police officer access to the requested medical records. Burn clients who surpass 20% Total Body Surface Area (TBSA) have massive shifts of fluid and electrolytes from intravascular to extravascular spaces, which can lead to cardiovascular collapse. Which assessment relates most directly to a diagnosis of Curling's ulcer? ️️Assess the gastric aspirate for pH and blood the color of coffee grounds. Fluid replacement is noted to be ideal if James produces how much output/hour? ️️Urine is recorded as hourly output of 30 mL/kg. James is receiving an escharotomy to treat his burn complications. Which information is accurate for the nurse provide to James' parents? ️️"The HCP will make an incision in James' leg to relieve the pressure." While caring for a client who has burns, which nursing intervention is essential in minimizing James' potential for infection? ️️-Inform James' family members that plants and flowers are not allowed in James' room. -Provide visitors with isolation gowns and instruction in hand hygiene. Cleaning the wound and preventing infection are priorities of care. James is scheduled for daily total immersion hydrotherapy. Which intervention should the nurse implement during James' hydrotherapy? ️️-Active range of motion exercises of his extremities.