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Published by: stuffednurse on Nov 13, 2008
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12/06/2012

 
NURSING PRACTICE 4Situation 1 - Because of the serious consequences of severe burns managementrequires a multi disciplinary approach. You have important responsibilities as anurse.While Sergio was lighting a barbecue grill with a lighter fluid, his shirt burstinto flames. The most effective wayto extinguish the flames with as little further damage as possible is to:a. log roll on the grass/groundb. slap the flames with his handsc. remove the burning clothesd. pour cold liquid over the flamesCORRECT ANSWER: ARATIONALE: Stop, drop and roll is a simple fire safety technique taught tochildren, emergency services personnel and industrial workers as a component ofhealth and safety training. Primarily, it is a method to extinguish a fire on aperson's clothes or hair without, or in addition to, the use of conventionalfirefighting equipment.In addition to extinguishing the fire, stop, drop and roll is an effectivepsychological tool, providing those in a fire situation, particularly children,with a routine that can be used to focus on in order to avoid panic.Stop, drop and roll consists of three components.·Stop - The fire victim must stop still. Ceasing any movement which may fanthe flames or hamper those attempting to put the fire out.·Drop - The fire victim must 'drop' to the ground, lying down if possible.·Roll - The fire victim must roll on the ground in an effort to extinguishthe fire by depriving it of oxygen. If the victim is on a rug or one is nearby,they can roll the rug around themselves to further extinguish the flame.The effectiveness of stop, drop and roll may be further enhanced by combining itwith other firefighting techniques,including the use of a fire extinguisher,dousing with water, or fire beating.2. Once the flames are extinguished, it is most important to:a. cover Sergio with a warm blanketb. give him sips of waterc. calculate the extent of his burnsd. assess Sergio's breathingCORRECT ANSWER: DRATIONALE: Thermal burns are caused by exposure to flames, hot liquids, steam orhot objects. Like this one, 1st priority should go to the assessment of breathingif there are no airway problems, possibility of inhalation of the smoke from theflames may cause smoke poisoning from by products of combustion. A localizedinflammatory reaction may occur, causing a decrease in bronchial ciliary actionand a decrease in surfactant. A compromised breathing may later on lead torespiratory complications. Assess for mucosal edema in the airways, after severalhours, sloughing of the tracheobronchial epithelium may occur, and hemorrhagicbronchitis may develop, ARDS can result.(Source: Saunders Comprehensive Review forthe NCLEX-RN exam 3rd Edition, p. 545)OPTION A: covering Sergio with a warm blanket will not benefit the situation sinceit can only increase heat and compromise comfort that should be provided forSergio.OPTION B: Although giving sips of water may help in the drying of the mucosa ofthe patient, it is first essential to assess the airway and breathing of thepatient as mucosal edema may be present and sips of water may result toaspiration.
 
OPTION C: Calculating the extent of the burn may be done after assessment of theABC’s which is very essential in providing care to the patient.Sergio is brought to the Emergency Room after the barbecue grill accident. Basedon the assessment of thephysician, Sergio sustained superficial partial thickness bums on his trunk, rightupper extremities ad rightlower extremities. His wife asks what that means. Your most accurate responsewould be:a. Structures beneath the skin are damagedb. Dermis is partially damagedc. Epidermis and dermis are both damagedd. Epidermis is damagedCORRECT ANSWER: DRATIONALE: Superficial partial thickness: These burns are superficial with injuryto the epidermis. These are first-degree burns and are characterized by erythema,edema, and pain; slight fluid loss, especially if less than 15% of the body isinvolved. Superficial partial-thickness burns heal spontaneously within 2-3 weeks,usually without scarring. Injured area is sensitive to cold air. Grafts may beused if healing process is prolonged.SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3rd edition,p. 544)OPTION A: is true for Deep Full-thickness burns as it involves injury to themuscle and bone.OPTION B: is true for Deep Partial-thickness burns as it involves the epidermisand superficial dermis causing erythema, pain, vesicles with oozing; fluid lossslight to moderate.OPTION C: is true for Full-thickness (3rd Degree) burn affects the epidermis,entire dermis and at times the subcutaneous tissue, resulting in charred or pearlywhite, dry skin and absence of pain; fluid loss usually severe, especially if morethan 2% of body surface is involved.(SOURCE: Mosby Comprehensive Review of Nursing for the NCLEX-RN exam 18th edition,p. 169.)4. During the first 24 hours after thermal injury, you should assess Sergio fora. hypokalemia and hypernatremiab. hypokalemia and hyponatremiac. hyperkalemia and hyponatremiad. hyperkalemia and HypernatremiaCORRECT ANSWER: CRATIONALE: Hyperkalemia can also result from injury to muscle or other tissues.Since most of the potassium in the body is contained in muscle, a severe traumathat crushes muscle cells results in an immediate increase in the concentration ofpotassium in the blood. Hyperkalemia result from severe burns for the 1st 24hours. Hyponatremia in burns occur due to low plasma osmolarity.(SOURCE: Silvestri Saunders Online Review Course,Fluid and Electrolyte Imbalance,p. 18)5. Teddy, who sustained deep partial thickness and full thickness burns of theface, whole anterior chest and bothupper extremities two days ago, begins to exhibit extreme restlessness. Yourecognize that this most likely indicates that Teddy is developing:a. Cerebral hypoxiab. Hypervolemiac. Metabolic acidosisd. Renal failure .
 
CORRECT ANSWER: ARATIONALE: Rarely do burn-injured clients suffer neurologic damage. The clientwith a major burn injury is most often awake and alert on admission to thehospital. If alteration in level of consciousness manifests, the client may besuffering from hypoxemia or hypovolemia and needs further assessment foridentifying the origin of these changes. It is most often related to impairedperfusion to the brain, hypoxia/hypoxemia (as in a closed space fire), inhalationinjury (as from exposure to asphyxiate or other toxic materials from the fire).Major burn injuries that may cause severe fluid loss can lead to a decrease inblood pressure, causing decreased cerebral perfusion, followed by impairedoxygenation to the brain. Neurologic manifestations may include headache,dizziness, memory loss, confusion or loss of consciousness, disorientation, visualchanges, hallucinations, combativeness and coma.(SOURCE: Med.-Surg. Nsg. By Black and Hawk 7th edition, vol.2, p.1441Situation 2 - You are now working as a staff nurse in a general hospital. You haveto be prepared to handle situations with ethico-legal and moral implications.6. You are on night duty in the surgical ward. One of our patients Martin isprisoner who sustained anabdominal gunshot wound. He is being guarded by policemen from the local policeunit. During your roundsyou heard a commotion. You saw the policeman trying to hit Martin. You asked whyhe was trying to hurt Martin. He denied the matter. Which among the followingactivities will you do first?a. Write an incident reportb. Call security officer and report the incidentc. Call your nurse supervisor and report the incident:d. Call the physician on dutyCORRECT ANSWER: ARATIONALE: The incident report is used as a means of identifying risk situationsand improving client care. Specific documentation guidelines are followed incompletion of the incident report. The criteria’s to formulating an incidentreport are as follows:·Accidental omission of ordered therapies·Circumstances that led to injury or a risk for client injury·Client falls·Medication administration errors·Needlestick injuries·Procedure-related or equipment-related accidents·A visitor having symptoms of an illness(SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3rd edition, p. 57)7. The nurse gives an inaccurate dose of a medication to a client. Followingassessment of the client, thenurse completes an incident report. The nurse notifies the nursingsupervisor of the medication error and callsthe physician to report the occurrence. The nurse who administered theinaccurate medication doseunderstands that the:a. error will result in suspensionb. incident report is a method of promoting quality care and riskmanagementc. incident will be reported to the board of nursingd. incident will be documented in the personnel file.CORRECT ANSWER: B

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