The nurse identifies that which patient with a burn injury most likely require endotracheal intubation or tracheostomy tube? The patient with:

chemical burns to the posterior neck, chest, and back

radiation burns to shoulder and bridge of nose

electrical burns to the hands causing dysrhythmias

thermal burns to the head, neck, face, and airway.

Answer and Explanation

The Correct Answer is D

A) Chemical burns to the posterior neck, chest, and back:
Chemical burns primarily affect the skin and underlying tissues where the chemicals have come into contact. Although chemical burns can cause significant damage, particularly to the respiratory system if inhaled, chemical burns to the posterior neck, chest, and back would not typically require endotracheal intubation or tracheostomy unless there is evidence of inhalation injury or airway compromise.

B) Radiation burns to shoulder and bridge of nose:
Radiation burns, such as those from sunburn or therapeutic radiation, generally do not cause immediate airway compromise or respiratory distress unless the radiation exposure has affected the lungs or upper respiratory tract.

C) Electrical burns to the hands causing dysrhythmias:
Electrical burns can cause significant tissue damage, especially if there is a deep tissue injury and potential for electrical burns to the internal organs. They can lead to dysrhythmias, but these burns are more related to cardiac complications rather than direct airway injury. Endotracheal intubation may be required if there are signs of airway compromise or respiratory failure, but the primary concern with electrical burns would be cardiac monitoring and fluid resuscitation.

D) Thermal burns to the head, neck, face, and airway:
The upper airway (including the mouth, throat, and vocal cords) is particularly vulnerable to thermal injury from inhaling hot gases, smoke, or steam. This can lead to edema and airway obstruction, which can rapidly progress to respiratory failure. Endotracheal intubation or even a tracheostomy may be required to secure the airway and prevent suffocation. Inhalation injury is a significant concern in thermal burns involving the head, neck, and face.

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Correct Answer is ["A","B","C","E"]

Explanation

A) Description of injury, vital signs during surgery, and current vital signs:
This information is crucial for the ICU nurse to understand the nature of the injury, how the patient responded during surgery, and their current hemodynamic status. Vital signs during surgery provide insight into the patient's cardiovascular stability and response to anesthesia, blood loss, and interventions. Current vital signs are important to monitor for any postoperative complications.

B) Description of operative procedure and patient tolerance:
The ICU nurse needs to know the details of the surgery performed, such as the type of trauma repair and any complications that may have occurred during the procedure. Understanding how the patient tolerated the surgery (e.g., any complications such as hypotension or arrhythmias) is important for planning post-operative care and anticipating potential issues in the ICU.

C) Total intake and output (IV fluids, blood products, urine/chest tube output, blood loss):
Tracking fluid balance is critical in trauma patients, especially those who have suffered significant blood loss. IV fluids, blood products, and other inputs (such as urine and chest tube output) provide vital information on the patient's circulatory status and renal function. Blood loss is also important to monitor, as it may need to be replaced, and fluid status affects the patient's recovery.

D) Presence of the patient's spiritual advisor and family:
Although family presence can be an important part of patient care, especially in a trauma situation, it is not essential information for the ICU nurse to receive during a report. While the ICU nurse may ask for family updates and visitor information, the focus of the report should be on the patient's clinical status and post-operative needs.

E) Medications administered during surgery and IV access sites:
The ICU nurse must know the medications administered during surgery, especially anesthesia agents, antibiotics, and analgesics, to understand their effects and anticipate any needed follow-up care, such as pain management or monitoring for adverse reactions. Knowing the IV access sites (e.g., central line, peripheral IV) is important for administering medications, fluids, and for monitoring potential complications related to vascular access.

A. includes the head-to-toe anterior and posterior assessment B. focuses on the ABCDE's to identify life threating problems C. includes the use of a standard pain scale and past medical/surgical history D. consists of analyzing the results of the diagnostic testing

Correct Answer is B

Explanation

A) Includes the head-to-toe anterior and posterior assessment:
While a head-to-toe physical assessment is important in trauma care, it is not the first priority. The primary assessment focuses on immediate life-threatening conditions, and the head-to-toe assessment would come after the initial stabilization of the patient's airway, breathing, circulation, and disability. A comprehensive physical examination is crucial but secondary to addressing urgent life threats.

B) Focuses on the ABCDE's to identify life-threatening problems:
The ABCDE's (Airway, Breathing, Circulation, Disability, Exposure) are the primary framework for assessing and stabilizing a trauma patient. This approach is used to identify and prioritize life-threatening problems. It ensures that the most critical issues, such as airway obstruction, respiratory failure, shock, and neurological deficits, are addressed first. This protocol is the gold standard in trauma care and is the most appropriate initial assessment in major trauma.

C) Includes the use of a standard pain scale and past medical/surgical history:
While it is important to assess pain and gather a medical history in the trauma patient, these are secondary considerations after addressing immediate threats to life. Pain management and obtaining a full history are crucial, but they are not as urgent as addressing airway, breathing, and circulation issues. These should be part of a more detailed secondary assessment once the patient is stable.

D) Consists of analyzing the results of the diagnostic testing:
Diagnostic testing, such as imaging studies and lab work, are important but are not the first priority. The primary assessment should focus on the ABCDE's. Diagnostic results are typically analyzed after the patient is stabilized, as they provide additional information but do not address immediate survival needs.

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The nurse identifies that which patient with a burn injury most likely require endotracheal intubation or tracheostomy tube? The patient with:

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Naxlex Comprehensive Predictor Exams

The Operating Room (OR) nurse is preparing to give report to the Intensive Care Unit (ICU) nurse on a patient who has had surgery after suffering penetrating chest and abdominal trauma. What should the nurse include in the report? (Select All that Apply.)

Correct Answer is ["A","B","C","E"]

Explanation

The nurse understands the primary assessment for a patient following a major trauma:

Correct Answer is B

Explanation

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