Six hours after a thermal burn, the nurse obtains the following assessment data for a patient who weighs 70 kg and has a 50% total body surface area (TBSA) burn. Which information is most important to communicate to the health care provider?

Serous exudate is leaking from the burns.

Urine output is 20 mL per hour for the past 2 hours.

Pulse rate of 104.

Blood pressure is 94/46 per arterial line.

Answer and Explanation

The Correct Answer is B

A. Serous exudate is leaking from the burns: Serous exudate is expected in the first hours after a thermal burn as part of the inflammatory response and capillary permeability. While it should be monitored for infection risk, it is not immediately life-threatening.

B. Urine output is 20 mL per hour for the past 2 hours: Oliguria is a critical indicator of inadequate perfusion and potential hypovolemic shock, especially in a patient with 50% TBSA burns who is in the fluid-shift phase. Low urine output signals insufficient renal perfusion and the need to adjust fluid resuscitation promptly, making it the most important data to report.

C. Pulse rate of 104: Mild tachycardia is expected after burns due to pain, stress, and fluid shifts. While it should be monitored, it is less immediately critical than evidence of organ hypoperfusion such as low urine output.

D. Blood pressure is 94/46 per arterial line: Hypotension in a burn patient is concerning, but early post-burn hypotension can be partially compensated by tachycardia. Urine output provides a more sensitive and direct measure of end-organ perfusion, which takes priority in communication with the provider.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Coumadin: Coumadin (warfarin) is an oral anticoagulant that inhibits vitamin K–dependent clotting factors. It is not effective in reversing the anticoagulant effects of heparin and would not be appropriate in the event of a heparin overdose.

B. Protamine sulfate: Protamine sulfate is a heparin antagonist that binds to heparin to form a stable complex, neutralizing its anticoagulant effect. It is administered intravenously and acts rapidly, making it the drug of choice for treating heparin overdose or excessive anticoagulation.

C. Enoxaparin: Enoxaparin is a low-molecular-weight heparin and functions similarly to unfractionated heparin by enhancing antithrombin III activity. It is not an antidote and would worsen anticoagulation if administered during a heparin overdose.

D. Vitamin K: Vitamin K is used to reverse the effects of vitamin K–dependent anticoagulants such as warfarin. It has no direct effect on heparin-induced anticoagulation and is not suitable for managing heparin overdose.

A. Providing oral fluids B. Stopping the burning process C. Covering with warm blankets D. Giving morphine

Correct Answer is B

Explanation

A. Providing oral fluids: While fluid replacement is important in burn victims, oral intake in the prehospital setting may be limited by airway compromise, nausea, or altered consciousness. Immediate fluid resuscitation is often deferred until intravenous access is established in a controlled setting.

B. Stopping the burning process: The priority in prehospital burn care is to halt the source of injury to prevent further tissue damage. This may involve extinguishing flames, removing the patient from hot surfaces, or chemical decontamination. Controlling the burn source directly limits injury progression and is the first and most critical intervention.

C. Covering with warm blankets: Covering the patient helps prevent hypothermia, which is a significant concern in extensive burns, but it is a secondary action after ensuring the burn source is eliminated. Warm blankets support stabilization but do not stop ongoing tissue damage.

D. Giving morphine: Pain management is essential, but analgesics do not prevent further injury. Administering morphine is secondary to stopping the burn source, securing the airway, and stabilizing the patient. Pain control is provided once the patient is safe from ongoing harm.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Six hours after a thermal burn, the nurse obtains the following assessment data for a patient who weighs 70 kg and has a 50% total body surface area (TBSA) burn. Which information is most important to communicate to the health care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse knows that which drug should be readily available in case a patient experiences a heparin overdose?

Correct Answer is B

Explanation

During prehospital care, what is the nurse's priority action for a burn victim?

Correct Answer is B

Explanation

The development of acute disseminated intravascular coagulation (DIC) is a critical setback for the patient. The nurse knows that which are common risk factors for the development of acute DIC? Select all that apply.

A nurse is caring for a patient with a head injury and increased intracranial pressure (ICP). Which of the following interventions should the nurse implement to help prevent an increase in ICP?

When caring for a patient with a head injury, a nurse must stay alert for signs and symptoms of increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP?

A nurse is assessing a patient and suspects the patient is experiencing disseminated intravascular coagulation (DIC). Which physical findings would the nurse expect?

A patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action will the nurse plan to take?

A patient who has been receiving a heparin infusion is diagnosed with heparin-induced thrombocytopenia (HIT). The nurse will anticipate which health care provider orders?

The nurse is explaining to a patient the difference between hemodialysis and continuous renal replacement therapy (CRRT). What statement by the patient leads the nurse to determine that additional education is needed?

The nurse implements the plan of care for a patient with bacterial meningitis. Which intervention(s) would the nurse plan to implement? Select all that apply.