Which of these patients is most appropriate for the burn unit charge nurse to assign to an RN staff nurse who has floated from the hospital medical unit?
A 60-year-old patient who has twice-daily burn debridements and dressing changes to partial-thickness facial burns.
A 45-year-old patient who has just come back to the unit after having a cultured epithelial autograft to the chest.
A 63-year-old patient who has blebs under an autograft on the thigh and has an order for bleb aspiration.
A 34-year-old patient who has a weight loss of 15
The Correct Answer is D
Choice A rationale
Facial burns involve complex airway management and specialized wound care that exceeds the typical scope of a medical unit nurse. Partial-thickness burns to the face require frequent assessment for edema, which can cause respiratory compromise. Debridement in this sensitive area involves meticulous technique to prevent infection and scarring. A float nurse lacks the specific burn-unit training required to manage these high-risk interventions and the associated pain management protocols effectively.
Choice B rationale
Cultured epithelial autografts are extremely fragile and expensive skin substitutes that require specialized nursing knowledge for successful engraftment. These grafts consist of thin layers of cells that can be easily dislodged or damaged by improper positioning or dressing contact. Nurses in a burn unit receive specific training on how to monitor these grafts for adherence and signs of rejection. A medical unit nurse would not be familiar with these critical post-operative protocols.
Choice C rationale
Bleb aspiration under an autograft is a delicate procedure that requires specific expertise to ensure the graft remains viable and attached to the wound bed. Fluid accumulation or blebs can prevent revascularization of the transplanted skin, leading to graft failure. This task is typically performed by experienced burn clinicians who understand the anatomy of skin grafting. Entrusting this to a float nurse would pose a significant risk to the patient's surgical outcome and recovery.
Choice D rationale
Weight loss is a common physiological response to the hypermetabolic state induced by major thermal injuries, but it is a condition that medical-surgical nurses are well-equipped to manage. Monitoring nutritional intake, administering supplements, and tracking daily weights are core competencies for any registered nurse. Since this patient is stable and the primary issue is metabolic support rather than acute burn wound or graft management, it is the most appropriate assignment for a float nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D"]
Explanation
Choice A rationale
This laboratory result represents metabolic acidosis, which is common in shock due to lactic acid accumulation from anaerobic metabolism. A pH of 7.22 is well below the normal range of 7.35 to 7.45. The bicarbonate level of 15 mEq/L is also low compared to the normal 22 to 26 mEq/L. These values indicate that the patient is still experiencing tissue hypoxia and inadequate perfusion, meaning the circulating volume and oxygen delivery have not been sufficiently restored.
Choice B rationale
These arterial blood gas values are within the normal physiological ranges. A pH of 7.35 is at the lower limit of normal, a PaCO2 of 40 mm Hg is exactly mid-range (normal 35 to 45 mm Hg), and a bicarbonate level of 22 mEq/L is at the lower limit of normal (normal 22 to 26 mEq/L). Achieving these values suggests that tissue perfusion is adequate to prevent the buildup of metabolic acids and that the respiratory system is effectively managing gas exchange.
Choice C rationale
The SaO2 measures the percentage of hemoglobin saturated with oxygen. A normal SaO2 value should be between 95 percent and 100 percent. A value of 76 percent is critically low and indicates severe hypoxemia. This could be due to continued blood loss, pulmonary complications from the trauma, or inadequate volume to transport oxygen. This measurement clearly demonstrates that the patient has not been stabilized and that the replacement of circulating volume and oxygenation is currently insufficient.
Choice D rationale
Normalization of vital signs and oxygen tension is a primary indicator of successful volume resuscitation. A blood pressure of 120/80 mm Hg and a pulse of 80 beats/minute are within standard normal limits, suggesting that the vascular space is adequately filled to maintain cardiac output. A PaO2 of 95 mm Hg is also within the normal range of 80 to 100 mm Hg, confirming that there is sufficient pressure to drive oxygen into the tissues following the transfusion.
Correct Answer is C
Explanation
Choice A rationale
Endotracheal intubation is indicated for respiratory failure or an inability to protect the airway. This patient is currently breathing spontaneously with an oxygen saturation of 95 percent, which is within the normal range of 95 to 100 percent. Intubation is an invasive procedure with risks such as ventilator associated pneumonia. It is not the priority intervention when clinical signs suggest an immediate mechanical issue like a tension pneumothorax or hemothorax resulting from the rib fractures.
Choice B rationale
Lactated Ringer's solution is used for fluid resuscitation in hypovolemic shock. While rib fractures can cause internal bleeding, giving a liter wide open without assessing the cause of respiratory distress can worsen outcomes, especially if the patient has a pulmonary contusion. The priority is addressing the mechanical compromise of the chest wall and pleural space. Excessive fluid can lead to pulmonary edema, further decreasing the efficiency of gas exchange in a patient with thoracic trauma.
Choice C rationale
Rib fractures from blunt chest trauma significantly increase the risk of a tension pneumothorax or hemothorax. A tension pneumothorax is a life threatening emergency where air enters the pleural space but cannot exit, increasing intrathoracic pressure. This shifts mediastinal structures and compresses the heart and great vessels, leading to obstructive shock. Needle thoracostomy provides immediate decompression of the pleural space, followed by chest tube insertion to restore negative pressure and allow for lung re-expansion.
Choice D rationale
A chest x-ray is a valuable diagnostic tool to identify the extent of rib fractures, presence of a pneumothorax, or pulmonary contusions. However, in the setting of acute thoracic trauma and potential respiratory compromise, waiting for imaging can delay life saving treatment. If a tension pneumothorax is suspected clinically based on symptoms and mechanism of injury, immediate decompression is required before radiographic confirmation. Assessment and intervention for airway, breathing, and circulation must always precede diagnostic imaging studies.
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