Burns AQ VERIFIED CORRECT ANSWERS 100% PASS 2023/202

Burns AQ VERIFIED CORRECT ANSWERS 100% PASS 2023/2024 A patient is brought to the emergency department (ED) with a history of inhalation injury from hot air in a manufacturing unit. The patient has also sustained burns on the face, neck, and hands. What actions should the nurse perform immediately? Select all that apply. Wait for laboratory reports. Observe for the next two hours. Perform early endotracheal intubation. Observe for signs of respiratory distress. Check for evidence of inhalation of smoke. - ANSWER Perform early endotracheal intubation. Observe for signs of respiratory distress. Check for evidence of inhalation of smoke. Checking for smoke inhalation is an important step to evaluate burn victims. Also, looking out for signs of respiratory distress like increased agitation, anxiety, restlessness, or a change in the rate or character of breathing is important. Early treatment includes airway management that involves early endotracheal (preferably orotracheal) intubation, because it eliminates the need for an emergency tracheostomy. Observing the patient for the next two hours does not help because treatment must begin at the earliest possible moment. In general, the patient suffering from burns on the face and neck may have mechanical obstruction caused by massive swelling of the tissues and requires intubation within one to two hours after the injury. During the care of the patient with a burn in the acute phase, which new interventions should the nurse expect to do after the patient progresses from the emergent phase? Monitor for signs of complications Assess and manage pain and anxiety Discuss possible reconstructive surgery Begin intravenous (IV) fluid replacement - ANSWER Monitor for signs of complications Monitoring for complications (e.g., wound infection, pneumonia, contractures) is needed in the acute phase. Fluid replacement occurs in the emergent phase. Assessing and managing pain and anxiety occurs in the emergent and the acute phases. Discussing possible reconstructive surgeries is done in the rehabilitation phase. The patient in the acute phase of burn care has electrical burns on the left side of the body, type 2 diabetes mellitus, and a serum glucose level of 485 mg/dL. What should be the nurse's priority intervention to prevent a life-threatening complication of hyperglycemia for this burned patient? Maintain a neutral pH Maintain fluid balance Replace the blood lost Replace serum potassium - ANSWER Maintain fluid balance This patient most likely is experiencing hyperosmolar hyperglycemic syndrome (HHS). HHS dehydrates a patient rapidly. Thus HHS combined with the massive fluid losses of a burn tremendously increases this patient's risk for hypovolemic shock and serious hypotension. This is clearly the nurse's priority , because the nurse must keep up with the patient's fluid requirements to prevent circulatory collapse caused by low intravascular volume. There is no mention of blood loss. Fluid resuscitation will help to correct the pH and serum potassium abnormalities. A patient who escaped from a burning building, which was enclosed with no ventilation, is brought to the emergency department. The patient is confused, has difficulty breathing, and has nasal burns. Which condition does the nurse suspect? Pulmonary edema Lower airway injury Upper airway injury Carbon monoxide poisoning - ANSWER Lower airway injury A patient who was trapped in an enclosed burning building with no ventilation and is exhibiting confusion, dyspnea, and nasal burns is most likely experiencing a lower airway burn injury. Pulmonary edema may occur but not until 12 to 24 hours after the initial insult. Clinical manifestations of an upper airway injury include blisters, edema, difficulty in swallowing, and total airway obstruction. Carbon monoxide poisoning results in hypoxia, in which oxygen consumption is impaired. Which fluid and electrolyte change occurs during the early emergent phase of burn injury? Increased excretion of urine Increased colloidal osmotic pressure Return of interstitial fluid to the vascular space Movement of sodium and water into interstitial fluids - ANSWER Movement of sodium and water into interstitial fluids After the burn, in the emergent phase, the capillary walls become more permeable, causing the movement of sodium, water, and plasma proteins into the interstitial spaces and surrounding tissues. An increased excretion of urine and the return of interstitial fluid to the vascular spaces occurs toward the end of the emergent phase. During the early emergent phase, colloidal osmotic pres