The nurse cares for a 55-year-old female admitted to the bur…
The nurse cares for a 55-year-old female admitted to the burn unit following a house fire. Nurses’ Notes 2000: A 55- year-old female arrives to the emergency department via ambulance with bilateral superficial partial thickness and deep partial thickness burns to the front of both legs, the entire right arm and the chest from a house fire that occurred at 1800 today. Client weighs 242 lbs. Fluid resuscitation started with Lactated Ringer’s IV in the emergency department. 2100: Admitted to the burn unit. Vital signs as noted. Morphine sulfate given for pain. Breath sounds clear. Client begins to appear edematous. Doppler pedal pulses present. A triple-lumen subclavian central venous line has been inserted to monitor the client’s central venous pressure (CVP). Vital Signs Time 2000 2100 Temperature 37.8 C/100 F 37.5 C/99.5 F Heart rate 130 135 Respirations 28 32 Blood pressure 88/58 80/54 Pulse oximeter 92 on 4L NC 98 on 100% Non-Rebreather (NRB) Pain 6/10 4/10 CVP 3 mmHg Intake & Output Hour 2000 2100 IV rate As ordered As ordered IV intake Started 689 mL Output 20 mL Which five client findings should the nurse report to the healthcare provider immediately? Select all that apply
Read DetailsA nurse is caring for a patient who sustained a 45% TBSA bur…
A nurse is caring for a patient who sustained a 45% TBSA burn 24 hours age. The client is exhibiting signs and symptoms of a pulmonary embolism. Which of the following factors contribute to the elevated risk of venous thromboembolsim (VTE) in burn patients? Select all that apply
Read DetailsA client is brought to the emergency room after being struck…
A client is brought to the emergency room after being struck by lightning during a thunderstorm. There is an entrance wound on the client’s left shoulder and an exit wound on the right calf. The nurse should prioritize which of the following interventions? Select all that apply
Read DetailsA 28-year-old presents to the emergency department with burn…
A 28-year-old presents to the emergency department with burns sustained in a kitchen accident. Upon assessment, the nurse observes redness, pain, and blistering over the affected area. The nurse recognizes these findings as indicative of which type of burn?
Read DetailsA 35-year-old patient is brought into the emergency departme…
A 35-year-old patient is brought into the emergency department after being involved in a house fire. Upon assessment, the nurse observes areas of charred, leathery skin with insensitivity to touch over the affected areas. The nurse recognizes these findings as indicative of which type of burn?
Read Details