The nurse is providing oral care to an unconscious patient. The nurse attempts to minimize any chance of aspiration of fluids by placing the patient in a When caring for a patient who is unconscious, it is still necessary to give oral care. The nurse must be careful to minimize any chance of aspiration of fluids.
A patient with partial-thickness burns is now allowed oral feedings. What nursing interventions should the nurse perform to maintain the patient's nutrition? 1. Suggest low-calorie food.
When performing a morning assessment on a terminally ill patient, the nurse observes a generalized purplish blotching of the patient's skin. The nurse documents this finding as Mottling is a purplish blotching of the skin when circulation slows greatly. A nurse applies hand mitts to a patient who has been repeatedly scratching himself.
When providing personal care to a child, the nurse should (select all that apply): When providing personal care to children, be sure to consider the modesty in school-age children and adolescents.
On the basis of this finding, the nurse would instruct the client to avoid foods high in sodium. Peas, nuts, and cauliflower are good food sources of phosphorus and are not high in sodium (unless they are canned or salted). Peas are also a good source of magnesium.
Rationale: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body.
A burn patient is about to receive a dressing change. The patient has dressings over both feet and lower legs and is receiving a continuous infusion of hydromorphone (Dilaudid). Which medication (s) is/are appropriate for the patient to receive before the dressing change is started? Select all that apply.
The patient will not need additional medication because the patient is receiving a continuous opioid infusion. 1, 4. Burn patients experience two kinds of pain: (1) continuous, background pain that might be present throughout the day and night; and (2) treatment-induced pain associated with dressing changes, ambulation, ...
An escharotomy (a scalpel incision through full-thickness eschar) frequently is required to restore circulation to compromised extremities . With full-thickness burns, myoglobin and hemoglobin released into the bloodstream can occlude renal tubules. Adequate fluid replacement is used to prevent this occlusion.
The patient should be provided with a high-protein diet to promote tissue healing and avoid malnutrition. A high-carbohydrate diet should be provided to meet the high metabolic demands. A low-calorie food may not meet the calorie requirements of the patient and leads to malnutrition and delayed wound healing.
1, 2, 5. Within 6 to 12 hours after the burn injury in which smoke inhalation is suspected, a fiberoptic bronchoscopy should be performed to assess the lower airway. Reposition the patient every one to two hours, and provide suctioning and chest physiotherapy, as prescribed, to clear the airway.
An infusion rate of 25 mL/hr is not sufficient to maintain adequate urine output in prevention and treatment of ATN. Mannitol also can be used to maintain urine output. The urine would be monitored also for the presence of myoglobin. Sodium bicarbonate may be given to alkalinize the urine.
Providing 100% oxygen does not ensure aerobic conditions at the burn area. Musculoskeletal relaxants will be helpful only after the patient develops tetanus. The nurse is planning care for a patient with partial- and full-thickness skin destruction related to burn injury of the lower extremities.