While performing wound care to a donor skin graft site, the nurse notes some scabbing around the edges and a dark collection of blood. What is the nurse's
... [Show More] next action?
Choose One
1. Leave the scabbing area alone and apply extra ointment.
2. Notify the primary healthcare provider.
3. Gently remove the debris and re-dress the wound.
4. Apply skin softening lotion for 3 hours and then re-dress.
3
Rationale
3. Correct: What likes to live in the scabs and dried blood? Bacteria. That is why it is important to remove the debris to prevent infection.
1. Incorrect: This is not appropriate because bacteria is in the scabbing area and ointment would trap it, enhance reproduction of the germs, and increase infection.
2. Incorrect: There is no need to notify primary healthcare provider at this time. This is not the best option for the nurse to fix the problem.
4. Incorrect: We don't put lotion in the wound because this would cause infection of the wound.
What information on burn prevention strategies should the nurse include when providing an education program at a community center?
Select All That Apply
1. Have chimney professionally inspected every 5 years.
2. Clean the lint trap on the clothes dryer after each use.
3. Keep anything that can burn at least 1 foot (0.30 meters) away from space heaters.
4. Do not hold a child while holding a hot drink.
5. Home hot water heater should be set at a maximum of 120°F (48.8°C).
2, 4, 5
Rationale
2., 4., & 5. Correct: Lint that accumulates in the lint trap of a dryer can cause a fire, so the lint trap should be cleaned after each use. A hot beverage can easily spill on a child by accident when trying to handle both the beverage and child at the same time. Home hot water heater should be set at a maximum of 120°F (48.8°C), especially when small children, the elderly, or diabetics are in the home.
1. Incorrect: A chimney should be professionally inspected every year prior to use. It should also be cleaned if necessary.
3. Incorrect: Space heaters need space at least three feet (0.91 meters) away from anything that can burn.
A client arrives at the emergency department after sustaining full thickness burns. What does the nurse estimate the total body surface area (TBSA) burned to be when using the rule of nines?
TRUNK + ARM
Posterior trunk = 18
Posterior arm = 4.5
TBSA burned = 22.5%
What immediate action should the occupational health nurse take once flames have been extinguished from a burned victim?
Choose One.
1. Remove jewelry.
2. Wrap in a clean blanket.
3. Cover burns with clean, dry cloth.
4. Briefly soak burned area in cool water.
4
Rationale
4. Correct: Although all options are correct, the priority is to stop the burning process. Just putting out the flames is not enough to stop the burning process. You need to apply cool water briefly (no more than 10 minutes) to soak the burn area. Any longer can cause extensive heat loss.
1. Incorrect: Removing jewelry is important but stop the burning process first. Swelling occurs with burns, so jewlrey must be removed or you will not get it off. This can result in constriction of the extemity. Additionally, metal burns.
2. Incorrect: Wrapping the client in a clean or preferably a sterile blanket will help to hold in body heat. Remember, they have lost skin, the number one way to hold in body heat.
3. Incorrect: Applying a clean, dry cloth to the burn area will help prevent infection, but the priority is to stop the burning process.
What sign/symptom would indictate to the nurse that a client has had an inhalation injury?
Select All That Apply
1. stridor
2. Swallowing difficulty
3. Singed nasal hair
4. Blisters to upper arms
5. Wheezing
1, 2, 3, 5
Rationale
1., 2., 3., & 5. Correct: Substernal/intercostal retraction and stridor are bad signs. Remember you will see difficulty swallowing, singed nasal and facial hair, and wheezing.
4. Incorrect: Blisters found on the oral/pharyngeal mucosa is more likely to indicate a smoke or inhalation injury.
An elderly client with partial and full-thickness burns has begun receiving fluids at 600 ml/hour, as determined by the Parkland (Consensus) Formula. Based on the assessment data for the first four hours, what should the nurse report to the primary healthcare provider?
Choose One
1. The cardiovascular system is becoming seriously overloaded
2. The speed of the IV should be reduced since CVP is now normal
3. The changes in vital signs indicate an expected response to fluids
4. The client is deteriorating because of age and extent of the burns
3
Rationale
3. CORRECT. The purpose of infusing large amounts of fluid into burn victims during the first 24 hours is to help maintain perfusion until the body's physiology returns to normal functioning. The serial vital signs indicate the cardiovascular system is stabilizing, as evidenced by pulse decreasing to the normal range while blood pressure increases. Though respirations are still slightly elevated, the client would likely be experiencing pain. Most importantly, the CVP (central venous pressure) has increased to the normal range, indicating the fluid replacement is adequate at this time.
1. INCORRECT. There is no evidence indicating possible cardiac overload. The client's vital signs are stabilizing and the central venous pressure (CVP) has returned to normal limits.
2. INCORRECT. When fluid replacement is calculated for burn clients, the amount is based on client weight in kilograms and total surface area burned. Those parameters do not change during the initial treatment. Therefore the amount of fluid needed during the first 24 hours remains unchanged until after that time frame, even if vital signs improve.
4. INCORRECT. The hourly data does not reflect deterioration. Vital signs are slowly returning to within normal range and there is no mention in the scenario about the extent of burns.
An elderly client arrives at the emergency room reporting a severe headache and blurred vision. The client indicates having awakened this morning with flu-like symptoms including nausea, vomiting and dizziness. The nurse notes the client appears very weak with shortness of breath and dark cherry red lips. Based on assessment findings, what life-threatening problem does the nurse expect?
Choose One
1. Guillian Barre
2. Severe dehydration
3. Advanced influenza
4. Carbon monoxide poisoning
4
Rationale
4. CORRECT. Carbon monoxide is a colorless, odorless, tasteless gas which permeates the blood stream, displacing the oxygen in hemoglobin. Symptoms are often confused with other illnesses, such as the flu. Assuming exposure is not fatal, the client may also experience extreme weakness, dizziness and blurred vision with confusion. Additionally, the carbon monoxide will cause lips and skin to become red in color. Without treatment, the client will die.
1. INCORRECT. Guillian-Barre is a muscle disorder occurring when the immune system attacks peripheral nerves, destroying the surrounding myelin sheath. The damage can develop over hours or days, but will take months to resolve. The client experiences severe weakness, drooping of the eye muscles and pain or tingling in hands and feet. The client also develops paresthesia and paralysis, which was not reported as symptoms in the scenario. Of major concern would be paralysis of the respiratory muscles.
2. INCORRECT. Although the client reported nausea and vomiting, there are no assessment findings in the scenario to corroborate severe dehydration.
3. INCORRECT. The client has reported flu-like symptoms, such as dizziness, nausea and vomiting along with headache. However, additional reported symptoms like blurred vision suggest a different problem.
A client with deep partial thickness burns to arms and legs is admitted to the burn unit. The nurse knows elevated results are most likely to be noted initially in what laboratory tests?
Select All That Apply
1. Hematocrit
2. Albumin
3. Potassium
4. Creatinine
5. Magnesium
1, 3, 4
Rationale
1, 3, & 4. CORRECT. The physiology of the body changes significantly following a major burn. Hematocrit increases as the fluid from the vascular spaces leaks into the interstitial tissues. Because of lysis of cells, potassium is released into the circulation, leading to hyperkalemia. The kidneys are impacted by the decreased cardiac output as well as the myoglobin released by the lysed cells. This causes creatinine to become elevated.
2. INCORRECT. Albumin, a body protein, is lost through the damaged skin areas and secondary to increased capillary permeability.
5. INCORRECT. Magnesium is a major electrolyte necessary for both muscle and nerve function. Since the body does not produce magnesium naturally, humans need a well-balanced diet which includes a variety of vegetables and seeds. Levels of magnesium are not affected during the initial period after a burn.
A client sustains a high-voltage electrical injury while at work. Which interventions should the occupational health nurse initiate?
Select All That Apply
1. Assess entry and exit wound.
2. Monitor vital signs.
3. Place on a spine board.
4. Connect to cardiac monitor.
5. Perform the rule of nines.
6. Apply cervical collar to neck.
1, 2, 3, 4, 6
Rationale
1., 2., 3., 4., & 6. Correct: You need to understand that high-voltage current of electricity damages the vascular system and the nerves nearby. This alteration in the vascular system can damage vital organs, so we worry about organ failure. Electrical burns have two wounds: an entrance burn wound that is generally small and an exit burn wound that is much larger. The electricity goes throughout the body causing damage, and then exits the body. So look for 2 burn wounds. Remember, vessels, nerves, and organs can be damaged. The nurse needs to monitor vital signs frequently, especially those assessing the respiratory and cardiac systems, since we worry about organ damage. Electricity can damage the heart muscle, so the client is at risk for dysrhythmias within 24 hours following an electrical burn. Put the client on continuous cardiac monitoring during this time. Why place the client on a spine board and put a c-collar on? Contact with electricity can cause muscle contractions strong enough to fracture bones, or vertebrae. The force of the electricity can actually throw the victim forcefully.
5. Incorrect: This statement is false. The rule of nines is not used for electrical burns, but for thermal burns. Most of the damage from electrical burns is internal and cannot be determined by using the rule of nines. [Show Less]