The nurse is caring for a client with 40% full thickness burned total body surface area (TBSA) in the Emergency Department. The nurse is awaiting transfer to a regional burn center within 20 minutes. What is the most appropriate initial wound care management while awaiting transfer?
Gently cleanse the wounds with warm soapy water
Remove blistered skin and cover with a dry dressing
Apply saline soaked wet-to-dry dressings
Cover with a clean dry sheet to prevent hypothermia
The Correct Answer is D
A. Gently cleanse the wounds with warm soapy water
Initial burn care focuses on preventing hypothermia and infection. Cleaning is usually performed in a controlled setting like a burn unit, not in the emergency phase.
B. Remove blistered skin and cover with a dry dressing
Blisters should not be removed in the initial phase unless they are large and tense. Removal increases the risk of infection.
C. Apply saline-soaked wet-to-dry dressings
Wet dressings can lead to hypothermia in burn patients, which worsens outcomes. Dry coverings are preferred.
D. Cover with a clean dry sheet to prevent hypothermia
Burn patients lose heat rapidly due to loss of skin integrity. Covering with a clean, dry sheet helps prevent hypothermia and infection before transfer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["31"]
Explanation
Flow rate=(Total volume×Drop factor​)÷ Time in minutes
= (250×15)÷120
= 31.25
Correct Answer is A
Explanation
A. Immediate removal of the cause of obstruction.
Cardiac tamponade is a life-threatening condition caused by fluid accumulation in the pericardium, which compresses the heart. The definitive treatment is pericardiocentesis to remove the fluid and relieve the obstruction.
B. Patient will be admitted for a cardiac catheterization.
While catheterization may be performed later for underlying cardiac disease, tamponade requires urgent intervention, not just admission.
C. Administering furosemide for its diuretic effects.
Diuretics reduce preload, which can worsen hypotension in tamponade by further decreasing cardiac output.
D. Withholding IV fluids due to fluid overload.
IV fluids may be used to maintain preload while waiting for pericardiocentesis. The issue is not volume overload but rather mechanical obstruction.
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