A patient is brought to the emergency department with partial thickness burns to their face, neck, arms, and chest after trying to put out a car fire.
The nurse should implement which nursing actions for this patient?
Administer oxygen as prescribed.
Restrict fluids.
Assess for airway patency.
Elevate extremities if no fractures are present.
Correct Answer : A,C,D
Choice A rationale
Burn injuries, especially those affecting the face, neck, and chest, significantly increase the risk of smoke inhalation and airway edema. Administering oxygen is crucial to counteract potential hypoxia resulting from impaired gas exchange in the lungs, carbon monoxide poisoning, and cellular anoxia. The goal is to maintain adequate tissue oxygenation and prevent respiratory failure, which is a leading cause of mortality in burn victims.
Choice B rationale
Fluid restriction is contraindicated in burn patients because they experience massive fluid shifts from the intravascular space into the interstitial spaces due to increased capillary permeability caused by the inflammatory response. This leads to hypovolemia and burn shock. Aggressive fluid resuscitation is necessary to maintain adequate circulating blood volume, tissue perfusion, and kidney function, preventing multi-organ system failure.
Choice C rationale
Assessing for airway patency is the absolute priority in a patient with burns to the face, neck, and chest. The heat and smoke can cause immediate laryngeal edema and subsequent upper airway obstruction, which can be life-threatening. The nurse must continuously monitor for signs such as stridor, hoarseness, and dyspnea, and prepare for potential intubation to secure the airway.
Choice D rationale
Elevating the extremities is a vital intervention for burn patients without fractures. The purpose of elevation is to reduce edema formation by promoting venous return and decreasing hydrostatic pressure in the burned limbs. This helps to maintain circulation, minimize tissue damage, and reduce pain. Edema is a major complication of burns due to the inflammatory response and increased capillary permeability.
Choice E rationale
Placing a cooling blanket on a burn patient is inappropriate and can be harmful. While cooling the burn area itself can decrease the inflammatory response, excessive cooling of the entire body, especially a large surface area, can lead to systemic hypothermia. Hypothermia impairs coagulation, decreases cardiac output, and can increase the risk of infection, all of which are detrimental to a burn patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Eczema, or atopic dermatitis, is a chronic inflammatory skin condition characterized by itchy, red, and swollen skin. While it can be patchy, it typically presents with weeping, crusting, and scaling, but not the thick, silvery scales characteristic of the described rash. Eczema often occurs in skin folds and flexural surfaces, distinguishing it from the patient's presentation.
Choice B rationale
Psoriasis is a chronic autoimmune condition causing an accelerated turnover of skin cells. This rapid proliferation leads to the formation of thick, red patches covered with characteristic silvery scales. The typical locations are the elbows, knees, and scalp, which perfectly matches the patient's presentation, making this the most likely diagnosis.
Choice C rationale
Scabies is a contagious infestation of the skin by the human itch mite. It presents as an intensely itchy rash, often with small, raised red bumps and burrows, typically found in skin folds, between fingers, and on the wrists. It does not produce the thick, silvery scales seen in the patient's rash, making this choice incorrect.
Choice D rationale
Seborrheic dermatitis is a common skin condition that mainly affects the scalp, causing flaky scales and red skin, and is commonly known as dandruff. While it can occur in other oily areas of the body, it does not typically present with the thick, silvery scales on the elbows and knees that are highly indicative of psoriasis. *.
Correct Answer is C
Explanation
Choice C rationale
Hypotension in a patient with a pneumothorax, especially a tension pneumothorax, is a significant indicator of decreased cardiac output. The accumulation of air in the pleural space increases intrathoracic pressure, which compresses the vena cava and the heart, impairing venous return to the right side of the heart. This reduces preload, leading to a profound decrease in stroke volume and cardiac output, resulting in hypotension and obstructive shock.
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