The burn unit nurse teaches a new staff nurse the priority nursing actions during the resuscitation phase of burn management. Which statement made by the inexperienced nurse indicates a need for further teaching?
1. "We should promote an increased oral fluid intake."
2. "A urinary catheter is usually inserted."
3. "I'll get a nasogastric tube and suction equipment ready."
4. "All patients should have a large-bore IV access if possible."
1
Rationale 1: "We should promote an increased oral fluid intake" is correct as a statement that requires further teaching. A nasogastric tube should be placed and suction applied to prevent aspiration; therefore, the patient will be NPO. This is also done to reduce the risk of the development of paralytic ileus.
Rationale 2: A urinary catheter should be placed prior to administering large boluses of fluids.
Rationale 3: This statement reflects an appropriate action and preparation.
Rationale 4: Patients with major burns entering this phase should have large-bore intravenous access for fluid administration.
You might also like to view...
The levator ani is a(n):
a. Imaginary line that divides the true and false pelvis. b. Basin-shaped structure at the lower end of the spine. c. Collection of three pairs of muscles. d. Division of the fallopian tube.
A nurse is ambulating a patient who catches her foot on the bed frame and begins to fall. Which of the following is an accurate step to prevent or minimize damage from this fall?
A) The nurse should place his or her feet close together with one foot in front of the other. B) The nurse should rock his or her pelvis out on the opposite side of the patient. C) The nurse should grasp the gait belt and pull the patient's body backward away from his or her body. D) The nurse should gently slide the patient down his or her body to the floor.
The nurse is aware that the characteristics of a full-thickness burn include: (Select all that apply.)
a. Leathery appearance b. Bright red color at the burn site c. Necessitates debridement d. Destroys on the dermis e. Pain only at the edges of the burn
A nurse would like to become involved in political action. Which of the following actions would be most appropriate for the nurse to accomplish this goal? (Select all that apply.)
a. Become a member of the state nurses association. b. Be friendly with everyone, whether supportive or not of your ideas. c. Don't expend time on local activities but ask to be appointed on the state level. d. Focus all your efforts on your specialty practice area and your employment site act.