The nurse is caring for a client with 40% full thickness burned total body surface area (TBSA) in the Emergency Department. The nurse is awaiting transfer to a regional burn center within 20 minutes. What is the most appropriate initial wound care management while awaiting transfer?
Gently cleanse the wounds with warm soapy water
Remove blistered skin and cover with a dry dressing
Apply saline soaked wet-to-dry dressings
Cover with a clean dry sheet to prevent hypothermia
The Correct Answer is D
A. Gently cleanse the wounds with warm soapy water
Initial burn care focuses on preventing hypothermia and infection. Cleaning is usually performed in a controlled setting like a burn unit, not in the emergency phase.
B. Remove blistered skin and cover with a dry dressing
Blisters should not be removed in the initial phase unless they are large and tense. Removal increases the risk of infection.
C. Apply saline-soaked wet-to-dry dressings
Wet dressings can lead to hypothermia in burn patients, which worsens outcomes. Dry coverings are preferred.
D. Cover with a clean dry sheet to prevent hypothermia
Burn patients lose heat rapidly due to loss of skin integrity. Covering with a clean, dry sheet helps prevent hypothermia and infection before transfer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E","F"]
Explanation
A. The correct rate is 6 mL/hr
The correct calculation should be verified.
B. After contacting the prescriber, Nurse A should anticipate an order for IV Vitamin K
Protamine sulfate, not vitamin K, is the antidote for heparin.
C. The nurses will complete an event report due to the medication error
A medication error must be reported.
D. Nurse A will document about the event report in the patient’s EMR
Incident reports are internal documents and should not be documented in the EMR.
E. The patient has received a dose of heparin over the prescribed amount
Due to the increased concentration, the patient received more heparin than intended.
F. The patient has received 3200 units of heparin from 1700-1900.
This calculation confirms overdosing.
Correct Answer is B
Explanation
A. Vocalization, strength, and pupillary response and accommodation are not components of GCS. Strength testing is part of a motor exam, and pupillary response is part of a cranial nerve assessment.
B. Eye opening, verbal response, and motor response are the three components of the Glasgow Coma Scale (GCS), which assesses a client’s neurological status and level of consciousness.
C. Pupillary reaction, eye opening, and motor response is incorrect because pupillary reaction is not a component of the GCS.
D. Motor response, sensory response, and level of consciousness is incorrect because sensory response is not a part of the GCS.
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