Author Question: The charge nurse observes the following actions being taken by a new nurse on the burn unit. Which ... (Read 39 times)

Hungry! · **on:** Jun 25, 2018

The charge nurse observes the following actions being taken by a new nurse on the burn unit. Which action by the new nurse would require an intervention by the charge nurse?

a. The new nurse uses clean latex gloves when applying antibacterial cream to a burn wound.
b. The new nurse obtains burn cultures when the patient has a temperature of 95.2 F (35.1 C).
c. The new nurse administers PRN fentanyl (Sublimaze) IV to a patient 5 minutes before a dressing change.
d. The new nurse calls the health care provider for a possible insulin order when a nondiabetic patient's serum glucose is elevated.

Question 2

Which patient is most appropriate for the burn unit charge nurse to assign to a registered nurse (RN) who has floated from the hospital medical unit?

a. A 34-year-old patient who has a weight loss of 15 from admission and requires enteral feedings.
b. A 67-year-old patient who has blebs under an autograft on the thigh and has an order for bleb aspiration
c. A 46-year-old patient who has just come back to the unit after having a cultured epithelial autograft to the chest
d. A 65-year-old patient who has twice-daily burn debridements and dressing changes to partial-thickness facial burns

gstein359 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: A
Sterile gloves should be worn when applying medications or dressings to a burn. Hypothermia is an indicator of possible sepsis, and cultures are appropriate. Nondiabetic patients may require insulin because stress and high calorie intake may lead to temporary hyperglycemia. Fentanyl peaks 5 minutes after IV administration, and should be used just before and during dressing changes for pain management.

Answer to Question 2

ANS: A
An RN from a medical unit would be familiar with malnutrition and with administration and evaluation of response to enteral feedings. The other patients require burn assessment and care that is more appropriate for staff who regularly care for burned patients.