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

Answer and Explanation

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.

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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.

A. Administer each unit of blood over 34 hour B. Anticipate an order for acetaminophen C. Anticipate an order for furosemide administration D. Assess for signs and symptoms of fluid overload E. Anticipate administration of FFP for the next transfusion

Correct Answer is ["A","C","D"]

Explanation

A. Administer each unit of blood over 3–4 hours

Older clients with CHF cannot tolerate rapid fluid shifts. Blood should be administered slowly (over 3–4 hours per unit) to prevent fluid overload.

B. Anticipate an order for acetaminophen

Acetaminophen is not routinely given before blood transfusions unless the client has a history of febrile reactions.

C. Anticipate an order for furosemide administration

Loop diuretics like furosemide may be ordered between units to prevent fluid overload in CHF patients.

D. Assess for signs and symptoms of fluid overload

CHF patients are at high risk for fluid overload, leading to dyspnea, crackles, and increased BP.

E. Anticipate administration of fresh frozen plasma (FFP) for the next transfusion

FFP is given for coagulation disorders, not for treating anemia in a GI bleed.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["C","E","F"]

Explanation

The nurse is caring for an 82-year-old client with a history of coronary artery disease. ML. and CHF. The client is to receive 2 units of packed red blood cells for acute blood loss from a Grbleed. What would be the nursing priorities for blood administration of this client? (Select All that Apply)

Correct Answer is ["A","C","D"]

Explanation

The nurse cannot auscultate bowel sounds during the assessment of a client who has had a repair of an abdominal aortic aneurysm four days ago. The client is complaining of severe abdominal pain and the abdomen is distended. What action should the nurse take at this time?

What action priority in preventing anaphylactic shock?

Which of the following measures would the nurse emphasize to assist the client diagnosed with trigeminal neuralgia in managing their pain?

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A client receiving treatment for severe burns over more than half of his body has an indwelling urinary catheter inserted. When evaluating the client's intake and output, which of the following should be taken into consideration? The amount of urine: