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 B

Explanation

A) Establish IV access, apply 2L O2 via nasal cannula, and notify provider:
While establishing IV access and providing oxygen are important aspects of managing many emergencies, this patient's symptoms suggest the presence of autonomic dysreflexia rather than a primary respiratory or circulatory issue. In autonomic dysreflexia, the primary concern is to remove the noxious stimulus (such as a full bladder, bowel impaction, or tight clothing) that is causing the severe hypertension and bradycardia.

B) Assess below injury for noxious stimuli, anticipate order for hypertensive medication:
The patient’s symptoms are consistent with autonomic dysreflexia, a serious condition that occurs in individuals with a spinal cord injury at or above the T6 level. The body’s autonomic nervous system overreacts to noxious stimuli (such as a distended bladder, bowel impaction, or skin irritation) below the level of injury, leading to a severe hypertensive crisis, bradycardia, and sympathetic hyperactivity. The nurse should immediately assess for and relieve any noxious stimuli below the injury level (e.g., checking for a full bladder, constipation, or tight clothing) and anticipate an order for antihypertensive medications if the blood pressure remains elevated.

C) Administer acetaminophen and initiate intravenous (IV) fluids, anticipate order for atropine:
While pain and discomfort (which can exacerbate autonomic dysreflexia) may need to be managed, acetaminophen is not the priority in this case. The priority is addressing the underlying cause of autonomic dysreflexia, such as relieving noxious stimuli. Additionally, atropine is used for bradycardia, but in autonomic dysreflexia, the bradycardia is secondary to the hypertensive crisis and usually resolves once the noxious stimulus is removed.

D) Lower the head of the bed and apply a cool compress to the forehead:
Although lowering the head of the bed may help reduce intracranial pressure and applying a cool compress may provide comfort, these interventions do not address the underlying cause of the autonomic dysreflexia.

A. Measure heart chamber pressures to assess for heart failure B. Determine cardiac output during the procedure. C. Evaluate the extent of the occlusion of the coronary arteries involved D. Prevent extensive myocardial damage

Correct Answer is D

Explanation

A) Measure heart chamber pressures to assess for heart failure:
Measuring heart chamber pressures is an important diagnostic tool in assessing heart failure, but it is not the primary goal in the case of a STEMI (ST-Elevation Myocardial Infarction). In STEMI, the primary goal is to identify and treat the blockage in the coronary arteries that is causing the heart attack.

B) Determine cardiac output during the procedure:
Cardiac output is a useful measurement for assessing heart function, but it is not the main focus during the treatment of STEMI. While monitoring cardiac output may be part of the overall care, the urgent priority in STEMI management is to restore blood flow to the affected myocardial tissue as quickly as possible to minimize damage, not to measure cardiac output.

C) Evaluate the extent of the occlusion of the coronary arteries involved:
While evaluating the extent of coronary artery occlusion is part of the process during a cardiac catheterization, the immediate priority for a patient with STEMI is to treat the blockage, not just evaluate it. While the angiogram will reveal the blockage, the treatment goal is to restore perfusion to the affected area of the heart through procedures such as balloon angioplasty or stent placement.

D) Prevent extensive myocardial damage:
This is the correct answer. The main goal of treatment for STEMI is to prevent extensive myocardial damage. In a STEMI, the coronary artery is blocked, depriving the heart muscle of oxygen, which can cause significant damage or death of the myocardial tissue. The most effective way to limit the extent of damage is to restore blood flow as quickly as possible, often through emergent procedures like percutaneous coronary intervention (PCI) or fibrinolytic therapy.

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Naxlex Comprehensive Predictor Exams

The nurse assesses the patient with a spinal cord injury at the level C-7 and finds warm, flushed skin with profuse sweating above the level of injury, and pale, cold skin below the level of injury. The patient is bradycardic, but severely hypertensive. What are the priority nursing interventions?

Correct Answer is B

Explanation

A client admitted to the Emergency Department with a suspected STEM. The nurse anticipates that this client will be immediately prepared for the cardiac catheterization laboratory as the goal of treatment is to:

Correct Answer is D

Explanation

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