A patient arrives in the emergency department with facial and ...

[penza]

A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first?
 
  a. Auscultate the patient's lung sounds.
  b. Determine the extent and depth of the burns.
  c. Infuse the ordered lactated Ringer's solution.
  d. Administer the ordered hydromorphone (Dilaudid).

Question 2

Eight hours after a thermal burn covering 50 of a patient's total body surface area (TBSA) the nurse assesses the patient. Which information would be a priority to communicate to the health care provider?
 
  a. Blood pressure is 95/48 per arterial line.
  b. Serous exudate is leaking from the burns.
  c. Cardiac monitor shows a pulse rate of 108.
  d. Urine output is 20 mL per hour for the past 2 hours.

[wilsonbho]

Answer to Question 1

ANS: A
A patient with facial and chest burns is at risk for inhalation injury, and assessment of airway and breathing is the priority. The other actions will be completed after airway management is assured.

Answer to Question 2

ANS: D
The urine output should be at least 0.5 to 1.0 mL/kg/hr during the emergent phase, when the patient is at great risk for hypovolemic shock. The nurse should notify the health care provider because a higher IV fluid rate is needed. BP during the emergent phase should be greater than 90 systolic, and the pulse rate should be less than 120. Serous exudate from the burns is expected during the emergent phase.