The Emergency Department (ED) nurse is assessing an 80-year-old patient who has superficial, partial thickness and deep partial thickness scald burns on bilateral anterior and posterior hands and forearms. The nurse estimates that the total body surface Tire CTBSA) burned is 27%. What should the nurse include in the emergent plan of care?

Start fluid resuscitation and prepare for transport co a Burn Center

Apply petroleum based antibiotic cream to the affected areas

Cover the burns with saline soaked gauze and medicated ointment

Clean the wounds with soap and room temperature water

Answer and Explanation

The Correct Answer is A

A) Start fluid resuscitation and prepare for transport to a Burn Center:
In this case, the patient has burns that cover 27% of the total body surface area (TBSA), which falls within the moderate to severe range for burn injuries. Fluid resuscitation is critical to prevent hypovolemic shock, a common complication of severe burns due to fluid loss. The "rule of nines" or Lund-Browder chart can be used to calculate the amount of fluids needed. The patient should also be prepared for transport to a specialized burn center, where advanced care can be provided for wound management, infection prevention, and long-term rehabilitation.

B) Apply petroleum-based antibiotic cream to the affected areas:
Although topical antibiotics are an essential part of burn care to prevent infection, petroleum-based ointments are typically not recommended in the emergent phase of burn management. Applying such creams could potentially trap heat and cause further tissue damage, and petroleum-based products can be occlusive, which may interfere with wound healing.
C) Cover the burns with saline-soaked gauze and medicated ointment:
While it is important to keep burns covered to prevent infection, the use of saline-soaked gauze and medicated ointments are more appropriate after initial fluid resuscitation and stabilization of the patient. Immediate burn care focuses on preventing further injury and initiating fluid resuscitation. Saline-soaked gauze is typically used in a controlled setting, like in a burn unit, and the patient's wounds should not be excessively covered with ointment during the emergent phase.

D) Clean the wounds with soap and room temperature water:
In burn management, cleaning the wounds with soap and water can disrupt the skin's protective barrier, particularly in the emergent phase. It is important to gently clean the wounds with sterile saline or an antiseptic solution and avoid harsh cleansers. Soap and water might cause irritation, exacerbate pain, and increase the risk of infection. The focus should be on stabilizing the patient and initiating proper wound management with sterile techniques.

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Correct Answer is A

Explanation

A) Provide honest answers to the client’s questions:
Providing honest answers to the client's questions is essential in promoting comfort, especially when they have a new diagnosis of bladder cancer. Patients often experience anxiety and uncertainty when facing a new diagnosis, so being open and transparent with information can help alleviate fears and build trust.

B) Avoid eye contact with the client during care:
Avoiding eye contact with the client can contribute to feelings of isolation and discomfort. Eye contact is an important form of non-verbal communication that can help establish a rapport and show empathy. Avoiding eye contact could make the client feel rejected or neglected, which would increase their anxiety and distress.

C) Provide limited explanations of procedures needed for care:
Providing limited explanations of procedures may leave the client feeling more confused or fearful about what is happening. While it's important to avoid overwhelming the patient with too much information, clear and concise explanations about procedures and treatments are essential to reduce anxiety and help the patient feel more in control of the situation.

D) Avoid giving the client choices regarding their care:
Avoiding giving the patient choices can make them feel powerless, which can increase feelings of anxiety and frustration. Offering choices when appropriate allows the patient to feel more in control of their care, which can reduce stress and enhance their sense of autonomy.

A. Urine output of 0.5-1 mL/kg/hr B. Serum sodium level 149 mEq/L. (normal 135-145) C. Blood pressure 82/54 D. Heart rate 124 beats per minute

Correct Answer is A

Explanation

A) Urine output of 0.5-1 mL/kg/hr:
This is a positive outcome during fluid resuscitation for burn patients. Adequate urine output is a key indicator of proper renal perfusion and fluid balance. A urine output of 0.5-1 mL/kg/hr is considered optimal for burn patients during the first 24-48 hours of resuscitation. It suggests that the kidneys are receiving sufficient blood flow and that the patient is responding appropriately to the fluids being administered.

B) Serum sodium level 149 mEq/L (normal 135-145):
A serum sodium level of 149 mEq/L is high and indicates hypernatremia, which is a common complication of excessive fluid resuscitation, particularly with the use of crystalloids. Hypernatremia can lead to cerebral edema, altered mental status, and other severe complications. Therefore, this finding would suggest improper fluid management and would not be considered a positive outcome.

C) Blood pressure 82/54:
A blood pressure of 82/54 is hypotensive, which is concerning in a burn patient. Hypotension indicates inadequate tissue perfusion, potentially leading to shock and organ failure. While low blood pressure may occur in the initial stages of resuscitation due to the rapid shifts in fluid, a sustained low blood pressure is not a positive outcome.

D) Heart rate 124 beats per minute:
A heart rate of 124 beats per minute is tachycardic and suggests that the patient is compensating for hypovolemia or inadequate circulatory volume, possibly due to insufficient fluid resuscitation. Although an elevated heart rate may occur as a compensatory mechanism in the initial stages of burn resuscitation, sustained tachycardia indicates ongoing volume depletion or inadequate perfusion and is not an ideal outcome.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a new diagnosis of bladder cancer Which of the following interventions should the nurse take to promote comfort?

Correct Answer is A

Explanation

The nurse is caring for patient with severe, major burns who is receiving fluid resuscitation per protocol. Which of the following assessments indicate positive outcome?

Correct Answer is A

Explanation

The nurse understands the primary assessment for a patient following a major trauma:

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