Patient with Burns; Prioritization & Delegation Review Questions

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NCLEX EXAM PREVIEW

110 terms kandykat1012Preview Seizures NCLEX 12 terms murkacatPreview Chapte 31 terms Brit When delegating care for patients on the burn unit, which patient should the charge nurse assign to an RN who has floated to the burn unit from the pediatric unit?

• A patient who is being discharged after 6 weeks on the

burn unit and who needs teaching about wound care

• A patient who has just been admitted after a high-

voltage electrical burn

• A patient who has a 25% total body surface area

(TBSA) burn injury and who has daily wound débridement prescribed

• A patient who is receiving IV lactated Ringer's solution

at 100 mL/hr (D)

• A patient who is receiving IV lactated Ringer's solution at 100 mL/hr

Rationale: An RN float nurse will be familiar with administration of IV fluids and with signs of fluid overload, such as shortness of breath. The other patients will require more specialized knowledge about assessment and interventions in burn injuries and should be assigned to RNs who have experience caring for patients with burn injuries.

The RN is teamed with a nursing assistant to provide care to patients on the burn unit. Which of these tasks can be safely delegated to the nursing assistant?

• Educating a patient in the rehabilitation phase of burn

injury about how to apply ointment to partial-thickness burns

• Changing a routine sterile dressing for a patient with a

circumferential partial-thickness burn on the chest and back

• Measuring and documenting hourly urine outputs for a

catheterized patient who was admitted yesterday with burns over 35% of TBSA

• Assessing the pain level using a 0-to-10 scale for a

burn patient who is using a fentanyl (Duramorph) patch for pain control (C)

• Measuring and documenting hourly urine outputs for a catheterized patient

who was admitted yesterday with burns over 35% of TBSA

Rationale: Measurement and documentation of urine output are included in

nursing assistant education and scope of practice. Assessing, patient teaching, and sterile dressing changes should be done by licensed nursing personnel.The nurse on a burn unit has just received change-of-shift report about these patients. Which patient should be assessed first?

• A 20-year-old patient admitted a week ago with deep

partial-thickness burns over 35% of the body who is complaining of pain at a level 7 (0-to-10 scale)

• A 26-year-old firefighter with smoke inhalation and

facial burns who has just arrived on the unit and whispers "I can't catch my breath!"

• A 50-year-old electrician who suffered external burn

injuries a month ago and is requesting that you call the doctor immediately about discharge plans

• A 60-year-old patient admitted yesterday with partial-

and full-thickness burns over 40% of the body who is receiving IV fluids at 250 mL/hr (B)

• A 26-year-old firefighter with smoke inhalation and facial burns who has just

arrived on the unit and whispers "I can't catch my breath!"

Rationale: Smoke inhalation and facial burns are associated with airway

inflammation and obstruction. The patient with difficulty breathing needs immediate assessment and intervention.A patient with partial-thickness wounds of the face and chest caused by a campfire is admitted to the burn unit.All of these actions have been prescribed by the physician. Which one should the nurse accomplish first?

• Give oxygen per non-rebreather mask at 100% FiO2.
• Infuse lactated Ringer's solution at 150 mL/hr.
• Give morphine sulfate 4 to 10 mg IV for pain control.
• Insert a 14-Fr retention catheter.

(A)

• Give oxygen per non-rebreather mask at 100% FiO2.

Rationale: Facial burns are frequently associated with upper airway inflammation.Administration of oxygen will assist in maintaining the patient's tissue oxygenation at an optimal level. The other actions should be implemented as quickly as possible after the oxygen therapy is initiated.

While working in the emergency department, the RN admits a patient with extensive burn injuries caused by a fire at the patient's home. Which assessment should the RN accomplish first?

• TBSA burned
• Breath sounds
• Pain level
• Blood pressure

(B)

• Breath sounds

Rationale: Respiratory complications are a major cause of death in patients who

have burn injuries. Adventitious breath sounds such as wheezes or decreased breath sounds may indicate the need for immediate intubation or tracheotomy.Which assessment information about a 60-kg patient who was admitted 12 hours ago with a full-thickness burn over 30% of the total body surface area will be of most concern to the nurse?

• The bowel sounds are absent.
• The pulse oximetry level is 91%.
• The serum potassium level is 8.1 mEq/L.
• The urine output since admission is 370 mL.

(C)

• The serum potassium level is 8.1 mEq/L.

Rationale: An elevated serum potassium level can cause cardiac arrest. The other findings are normal for the patient during the emergent phase of burn injury.A patient is admitted with a full-thickness scald burn over the abdomen and thighs, and all of these physician orders are received. Which order should be implemented first?

• Place two large-bore IV lines.
• Insert a 16-Fr retention catheter.
• Obtain a complete blood count.
• Administer tetanus toxoid 0.5 mL.

(A)

• Place two large-bore IV lines.

Rationale: The priority nursing actions at this time are ensuring adequate

oxygenation and tissue perfusion. Because there is no indication that the patient is having respiratory difficulties, the initial nursing action should be to start fluid resuscitation, which will require large-bore IV lines. The other actions should also be implemented rapidly but are not the highest-priority actions.