The patient arrives at the emergency department with full-thickness burns over the entire chest and back. What is the patient's priority need? A. Fluid resuscitation B. Intravenous (IV) antibiotics C. Tetanus immunization D. Intramuscular (IM) analgesic A. Fluid resuscitation Rationale Fluid resuscitation is a priority in treating extensive full-thickness burns because of the risk of hypovolemic shock from fluids shifting out of blood vessels due to increased capillary permeability. This phase can begin as early as 20 minutes after the burn. Antibiotics and tetanus immunization are important, but fluid volume is a priority. Pain relief is not a priority because the nerve endings are destroyed, and IV analgesics should be given because absorption through the IM route is inadequate in the burned or edematous areas. Reference: 479 The patient walks to the emergency department in clothing saturated with alkali solution after a can of drain cleaner exploded at home a few minutes earlier. What nursing action is most important? A. Assess the patient's lungs. B. Administer a tetanus immunization. C. Wash the skin with copious amounts of water. D. Obtain a set of vital signs. C. Wash the skin with copious amounts of water. Rationale Alkali burns, such as caused by oven and drain cleaners, damage the tissue because the chemicals adhere and cause protein hydrolysis and liquefaction. Patients with chemical burns should have clothing removed and the affected area flushed with copious amount of water. Reference: 479, Table 25-8 The patient sustained a full-thickness burn encompassing the entire right arm. What is the best indicator an escharotomy achieved its desired effect? A. Patient rates the pain at less than 4. B. Blood pressure remains above 120/80 mm Hg. C. Right fingers blanch with a 2-second refill. D. Patient maintains full range of motion for the right arm. C. Right fingers blanch with a 2-second refill. Rationale Circulation to the extremities can be severely impaired by deep circumferential burns and subsequent edema that impairs the blood supply. An escharotomy (electrocautery incision through the full-thickness eschar) is performed to restore circulation. Normal refill is less than 2 seconds. Reference: 480 Multiple patients arrive in the emergency department from a house fire. Which patient is a priority? A. Patient with erythremic, dry burns over the arms and a history of taking prednisone B. Patient with moist blisters over the chest and who reports pain as 10 C. Patient with dry, black skin on one hand and a history of diabetes mellitus D. Patient with multiple reddened skin areas on the chest and with high-pitched respiratory sounds D. Patient with multiple reddened skin areas on the chest and with high-pitched respiratory sounds Rationale Airway injury is a priority, and stridor results from a narrowing of the airway caused by edema. A history of prednisone use or diabetes is a concern for long-term infection risk, but the airway is always first.
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- Winter '16
- Nursing, c. Lactated Ringer