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 C

Explanation

A) Prevent the drainage by applying a tight pressure dressing:
Applying a tight pressure dressing is not the appropriate intervention in this case. The presence of fluid draining from the ear, particularly a yellow stain, could indicate cerebrospinal fluid (CSF) leakage, which is a potential sign of a skull fracture or traumatic brain injury (TBI) involving the base of the skull. Applying a tight pressure dressing could potentially increase pressure or cause further injury.

B) Administer antibiotics due to increased risk of infection:
While there is an increased risk of infection with a CSF leak, antibiotics should not be administered immediately unless there is clear evidence of an infection. The priority action is to identify whether the fluid is CSF, as antibiotics alone will not address the underlying issue of a CSF leak. The nurse should allow the fluid to drain, collect a sample, and notify the healthcare provider for further assessment, which may include imaging or testing for the presence of CSF.

C) Allow fluid to drain from the patient's ear onto gauze and notify the healthcare provider:
The yellow stain around the fluid dripping from the patient's ear suggests the possibility of CSF leakage, a sign of a skull base fracture. CSF leakage may occur after a traumatic brain injury and should be handled carefully. The nurse's priority action is to allow the fluid to drain onto gauze to prevent the buildup of pressure and to prevent further leakage into the ear canal. The nurse should also immediately notify the healthcare provider for further evaluation and management.

D) Hang intravenous (IV) fluids to replace fluids lost and prevent dehydration:
While IV fluids may be necessary in some cases for patients with trauma, the priority in this situation is to identify the source and nature of the drainage. If the fluid is CSF, it may be important to manage the leak appropriately rather than focusing solely on replacing fluids. The nurse should first confirm whether the fluid is CSF and notify the healthcare provider for further assessment and management. Replacing fluids may be necessary, but it is not the immediate priority.

A. Assess lung sounds and respiratory rate at least every 2 hours B. Assess and document pain level once every shift C. Maintain sequential compression device (SCD's) while in bed D. Elevate the head of the bed ten degrees

Correct Answer is A

Explanation

A) Assess lung sounds and respiratory rate at least every 2 hours:
In a patient with Myasthenia Gravis (MG) who has undergone thymectomy, monitoring respiratory status is critical. MG is a neuromuscular disorder that can lead to respiratory muscle weakness, which may be exacerbated post-operatively. Assessing lung sounds and respiratory rate at least every 2 hours is crucial to detect early signs of respiratory compromise, including hypoventilation or atelectasis.

B) Assess and document pain level once every shift:
While pain assessment is important, especially after a thymectomy, this action alone does not directly address the immediate issue of ineffective breathing patterns. In patients with MG, respiratory complications are a priority concern. Pain management should be part of the overall plan of care, but it is secondary to monitoring respiratory function in the acute post-operative period. Pain can affect respiratory effort, but it should be managed in the context of more pressing issues like airway and breathing assessment.

C) Maintain sequential compression device (SCD's) while in bed:
While SCDs are important in preventing deep vein thrombosis (DVT) in patients who are immobile, they are not the most appropriate intervention for a client with ineffective breathing patterns. The primary concern in a post-thymectomy patient with MG is respiratory function.

D) Elevate the head of the bed ten degrees:
While elevating the head of the bed can help with comfort and potentially improve ventilation in some patients, it is not the most specific or effective intervention for managing ineffective breathing patterns in a patient with MG. For optimal respiratory function, it is typically more beneficial to elevate the head of the bed to a higher degree (e.g., 30-45 degrees) to enhance lung expansion, rather than just 10 degrees.

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Naxlex Comprehensive Predictor Exams

The nurse notices a yellow stain around fluid dripping from a patient’s ear who sustained a traumatic brain injury. The nurse's priority intervention will be as follows:

Correct Answer is C

Explanation

The nurse is caring for a client diagnosed with Myasthenia Gravis (MG) who is post op thymectomy. The client problem is Ineffective Breathing Pattern, Which action would the nurse include in the plan of care?

Correct Answer is A

Explanation

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