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NCLEX-RN · Question #259

An 11-year-old boy has received a partial-thickness burn to both legs. He presents to the emergency room approximately 15 minutes after the accident in excruciating pain with charred clothing to…

The correct answer is D. Immerse both legs in cool water. (A) Ice creates a dramatic temperature change in the tissue, which can cause further thermal (B) Charred clothing should not be removed from wound first. This creates further tissue damage. Débridement is not the first nursing action. (C) Applying silver sulfadiazine cream…

Physiological Integrity: Physiological Adaptation

Question

An 11-year-old boy has received a partial-thickness burn to both legs. He presents to the emergency room approximately 15 minutes after the accident in excruciating pain with charred clothing to both legs. What is the first nursing action?

Options

  • AApply ice packs to both legs.
  • BBegin débridement by removing all charred clothing from wound. all charred clothing from wound.
  • CApply Silvadene cream (silver sulfadiazine).
  • DImmerse both legs in cool water.

How the community answered

(46 responses)
  • A
    2% (1)
  • B
    2% (1)
  • C
    4% (2)
  • D
    91% (42)

Explanation

(A) Ice creates a dramatic temperature change in the tissue, which can cause further thermal (B) Charred clothing should not be removed from wound first. This creates further tissue damage. Débridement is not the first nursing action. (C) Applying silver sulfadiazine cream first insulates heat in injured tissue and increases potential (D) Emergency care of a thermal burn is immersing both legs in cool water. Cool water permits gradual temperature change and prevents further thermal damage.

Topics

#burn first aid#partial-thickness burn#emergency burn care#wound cooling

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