A patient has been brought to the emergency department by ambulance after sustaining major burns in a house fire
The nurse would anticipate that which therapies have been initiated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Jewelry has been removed.
2. Ice bags have been applied to burned areas.
3. The burn has been covered with a clean sheet.
4. Tetanus prophylaxis status has been determined.
5. Burn ointment has been applied to all partial-thickness burns.
1,3,4
Rationale 1: Jewelry that might add to the burn injury should be removed as part of prehospital care.
Rationale 2: Ice should not be applied due to the possibility of additional injury.
Rationale 3: Placement of a clean sheet over the burned area may reduce pain and protect the wound.
Rationale 4: The patient with burn injury is at risk for tetanus. Depending on the date of the last tetanus injection, a form of tetanus prophylaxis will likely be necessary.
Rationale 5: Ointment should not be applied to any burns.
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