Page 2436 - Saunders Comprehensive Review For NCLEX-RN

g. Remove constricting jewelry and
clothing.
h. Insert IV access.
i. Transport to the emergency department.
2. Emergency department care is a continuation of care
administered at the scene of the injury.
3. Major burns
a. Evaluate the degree and extent of the
burn and treat life-threatening
conditions.
b. Ensure a patent airway and administer
100% oxygen as prescribed.
c. Monitor for respiratory distress and
assess the need for intubation.
d. Assess the oropharynx for blisters and
erythema; assess vocal quality and for
singed nasal hairs and auscultate lung
sounds.
e. Monitor arterial blood gases and
carboxyhemoglobin levels.
f. For an inhalation injury, administer
100% oxygen via a tight-fitting
nonrebreather face mask as prescribed
until the carboxyhemoglobin level falls
below 15%.
g. Initiate peripheral IV access to
nonburned skin proximal to any
extremity burn, or prepare for the
insertion of a central venous line as
prescribed.
h. Assess for hypovolemia and prepare to
administer fluids intravenously to
maintain fluid balance.
i. Monitor vital signs closely.
j. Insert a Foley catheter as prescribed, and
manage fluid resuscitation with a goal
to maintain urine output at 30 to
50 mL/hr.
k. Maintain NPO (nothing by mouth)
status.
l. Insert a nasogastric tube as prescribed to
remove gastric secretions and prevent
aspiration.
m. Administer tetanus prophylaxis as
prescribed.
n. Administer pain medication, as
prescribed, by the IV route.
o. Administer wound care and prepare

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