chapter 24 burns review
A patient is admitted to the burn unit with second- and third-degree burns covering the face, entire right upper extremity, and right anterior trunk area. Using the rule of nines, what should the nurse calculate the extent of these burns as being? 18% 22.5% 27% 36%
22.5% Using the rule of nines, for these second- and third-degree burns, the face encompasses 4.5% of the body area, the entire right arm encompasses 9% of the body area, and the entire anterior trunk encompasses 18% of the body area. Because the patient has burns on only the right side of the anterior trunk, the nurse would assess that burn as encompassing half of the 18%, or 9%. Therefore, adding the three areas together (4.5 + 9 + 9), the nurse would correctly calculate the extent of this patient's burns to cover about 22.5% of the total body surface area.
In caring for a patient with burns to the back, the nurse knows that the patient is moving out of the emergent phase of burn injury when what is observed? Serum sodium and potassium increase. Serum sodium and potassium decrease. Edema and arterial blood gases improve. Diuresis occurs and hematocrit decreases.
Diuresis occurs and hematocrit decreases. Toward the end of the emergent phase, fluid loss and edema formation end. Interstitial fluid returns to the vascular space and diuresis occurs. Urinary output is the most commonly used parameter to assess the adequacy of fluid resuscitation. The hemolysis of red blood cells (RBCs) and thrombosis of burned capillaries also decreases circulating RBCs. When the fluid balance has been restored, dilution causes the hematocrit levels to drop. Initially sodium moves to the interstitial spaces and remains there until edema formation ceases, so sodium levels increase at the end of the emergent phase as the sodium moves back to the vasculature. Initially potassium level increases as it is released from injured cells and hemolyzed RBCs, so potassium levels decrease at the end of the emergent phase when fluid levels normalize.
The nurse is planning care for a patient with partial- and full-thickness skin destruction related to burn injury of the lower extremities. Which interventions will the nurse include in this patient's care? (Select all that apply.) Escharotomy Administration of diuretics IV and oral pain medications Daily cleansing and debridement Application of topical antimicrobial agent
Escharotomy IV and oral pain medications Daily cleansing and debridement Application of topical antimicrobial agent An escharotomy (a scalpel incision through full-thickness eschar) is frequently required to restore circulation to compromised extremities. Daily cleansing and debridement as well as application of an antimicrobial ointment are expected interventions used to minimize infection and enhance wound healing. Pain control is essential in the care of a patient with a burn injury. With full-thickness burns, myoglobin and hemoglobin released into the bloodstream can occlude renal tubules. Adequate fluid replacement is used to prevent this occlusion.
An older adult is moving into an independent living facility. What teaching will prevent this patient from being accidently burned in the new home? Encourage her to stop smoking. Install tap water anti-scald devices. Ensure all meals are cooked for her. Be sure she uses an open space heater.
Install tap water anti-scald devices. Installing tap water anti-scald devices will help prevent accidental scald burns that more easily occur in older people as their skin becomes drier and the dermis thinner. Cooking for her may be needed at times of illness or in the future, but she is moving to an independent living facility, so at this time she should not need this assistance. Stopping her from smoking may be helpful to prevent burns but may not be possible without the requirement by the facility. Using an open space heater would increase her risk of being burned and would not be encouraged.
The patient in the emergent phase of a burn injury is being treated for severe pain. What medication should the nurse anticipate administering to the patient? Subcutaneous (SQ) tetanus toxoid Intravenous (IV) morphine sulfate Intramuscular (IM) hydromorphone Oral oxycodone and acetaminophen
Intravenous (IV) morphine sulfate IV medications are used for burn injuries in the emergent phase to rapidly deliver relief and prevent unpredictable absorption that would occur with the IM route. The PO route is not used because GI function is slowed or impaired because of shock or paralytic ileus, although oxycodone and acetaminophen may be used later in the patient's recovery. Tetanus toxoid may be administered but not for pain.
When caring for a patient with an electrical burn injury, which order from the health care provider should the nurse question? Mannitol 75 gram IV Urine for myoglobulin Lactated Ringer's solution at 25 mL/hr Sodium bicarbonate 24 mEq every 4 hours
Lactated Ringer's solution at 25 mL/hr Electrical injury puts the patient at risk for myoglobinuria, which can lead to acute renal tubular necrosis (ATN). Treatment consists of infusing lactated Ringer's solution at 2 to 4 mL/kg/%TBSA, a rate sufficient to maintain urinary output at 75 to 100 mL/hr. Mannitol can also be used to maintain urine output. Sodium bicarbonate may be given to alkalinize the urine. The urine would also be monitored for the presence of myoglobin. An infusion rate of 25 mL/hr is not sufficient to maintain adequate urine output in prevention and treatment of ATN.
A patient with type 2 diabetes is in the acute phase of burn care with electrical burns on the left side of the body and a serum glucose level of 485 mg/dL. What is the nurse's priority intervention for this patient? Replace the blood lost. Maintain a neutral pH. Maintain fluid balance. Replace serum potassium.
Maintain fluid balance. This patient most likely has hyperosmolar hyperglycemic syndrome (HHS). HHS dehydrates a patient rapidly. HHS combined with the massive fluid losses of a burn tremendously increase this patient's risk for hypovolemic shock and serious hypotension. This is clearly the nurse's priority because the nurse must keep up with the patient's fluid requirements to prevent circulatory collapse caused by low intravascular volume. There is no mention of blood loss. Fluid resuscitation will help to correct the pH and serum potassium abnormalities.
The nurse is planning care for the patient in the acute phase of a burn injury. What nursing action is important for the nurse to perform after the progression from the emergent to the acute phase? Begin IV fluid replacement. Monitor for signs of complications. Assess and manage pain and anxiety. Discuss possible reconstructive surgery.
Monitor for signs of complications. Monitoring for complications (e.g., wound infection, pneumonia, contractures) is needed in the acute phase. Fluid replacement occurs in the emergent phase. Assessing and managing pain and anxiety occurs in the emergent and the acute phases. Discussing possible reconstructive surgeries is done in the rehabilitation phase.
The nurse is planning to change the dressing that covers a deep partial-thickness burn of the right lower leg. Which prescribed medication should the nurse administer to the patient 30 minutes before the scheduled dressing change? Morphine Sertraline Zolpidem Alprazolam
Morphine Deep partial-thickness burns result in severe pain related to nerve injury. The nurse should plan to administer analgesics before the dressing change to promote patient comfort. Morphine is a common opioid used for pain control. Sedative/hypnotics and antidepressant agents also can be given with analgesics to control the anxiety, insomnia, and depression that patients may have.
A patient arrives in the emergency department after sustaining a full-thickness thermal burn to both arms while putting lighter fluid on a grill. What manifestations should the nurse expect? Severe pain, blisters, and blanching with pressure Pain, minimal edema, and blanching with pressure Redness, evidence of inhalation injury, and charred skin No pain, waxy white skin, and no blanching with pressure
No pain, waxy white skin, and no blanching with pressure With full-thickness burns, the nerves and vasculature in the dermis are destroyed so there is no pain, the tissue is dry and waxy-looking or may be charred, and there is no blanching with pressure. Severe pain, blisters, and blanching occur with partial-thickness (deep, second-degree) burns. Pain, minimal edema, blanching, and redness occur with partial-thickness (superficial, first-degree) burns.
A nurse is caring for a patient with second- and third-degree burns to 50% of the body. The nurse prepares fluid resuscitation based on knowledge of the Parkland (Baxter) formula that includes which recommendation? The total 24-hour fluid requirement should be administered in the first 8 hours. One half of the total 24-hour fluid requirement should be administered in the first 4 hours. One half of the total 24-hour fluid requirement should be administered in the first 8 hours. One third of the total 24-hour fluid requirement should be administered in the first 4 hours.
One half of the total 24-hour fluid requirement should be administered in the first 8 hours. Fluid resuscitation with the Parkland (Baxter) formula recommends that one half of the total fluid requirement should be administered in the first 8 hours, one quarter of total fluid requirement should be administered in the second 8 hours, and one quarter of total fluid requirement should be administered in the third 8 hours.
The patient received a cultured epithelial autograft (CEA) to the entire left leg. What should the nurse include in the discharge teaching for this patient? Sit or lie in the position of comfort. Wear a pressure garment for 8 hours each day. Refer the patient to a counselor for psychosocial support. Use the sun to increase the skin color on the healed areas.
Refer the patient to a counselor for psychosocial support. In the rehabilitation phase, the patient will work toward resuming a functional role in society, but frequently there are body image concerns and grieving for the loss of the way the patient looked and functioned before the burn, so continued counseling helps the patient in this phase as well. Putting the leg in the position of comfort is more likely to lead to contractures than to help the patient. If a pressure garment is prescribed, it is used for 24 hours/day for as long as 12 to 18 months. Sunlight should be avoided to prevent injury, and sunscreen should always be worn when the patient is outside.
The nurse is caring for a patient who sustained a deep partial-thickness burn to the anterior chest area during a workplace accident 6 hours ago. Which assessment findings would the nurse identify as congruent with this type of burn? Skin is hard with a dry, waxy white appearance. Skin is shiny and red with clear, fluid-filled blisters. Skin is red and blanches when slight pressure is applied. Skin is leathery with visible muscles, tendons, and bones.
Skin is shiny and red with clear, fluid-filled blisters. Deep partial-thickness burns have fluid-filled vesicles that are red and shiny. They may appear wet (if vesicles have ruptured), and mild to moderate edema may be present. Superficial partial-thickness burns are red and blanch with pressure vesicles that appear 24 hours after the burn injury. Full-thickness burns are dry, waxy white, leathery, or hard, and there may be involvement of muscles, tendons, and bones.
A patient with a burn inhalation injury is receiving albuterol for the treatment of bronchospasm. What is the most important adverse effect of this medication for the nurse to monitor? Tachycardia Restlessness Hypokalemia Gastrointestinal (GI) distress
Tachycardia Albuterol stimulates β-adrenergic receptors in the lungs to cause bronchodilation. However, it is a noncardioselective agent, so it also stimulates the β-receptors in the heart to increase the heart rate. Restlessness and GI upset may occur but will decrease with use. Hypokalemia does not occur with albuterol.
The nurse is caring for a 71-kg patient during the first 12 hours after a thermal burn injury. Which outcomes indicate adequate fluid resuscitation? (Select all that apply.) Urine output is 46 mL/hr. Heart rate is 94 beats/min. Urine specific gravity is 1.040. Mean arterial pressure is 54 mm Hg. Systolic blood pressure is 88 mm Hg.
Urine output is 46 mL/hr. Heart rate is 94 beats/min. Assessment of the adequacy of fluid resuscitation is best made using either urine output or cardiac factors. Urine output should be 0.5 to 1 mL/kg/hr (or 75 to 100 mL/hr for an electrical burn patient with evidence of hemoglobinuria/myoglobinuria). Cardiac factors include a mean arterial pressure (MAP) greater than 65 mm Hg, systolic BP greater than 90 mm Hg, and heart rate less than 120 beats/min. Normal range for urine specific gravity is 1.003 to 1.030.
patient with partial thickness burns is being treated with zolpidem, family asks why they're getting this med. which response is appropriate? a "it is used to promote sleep" b "it is used to reduce anxiety" c "it is used to promote wound healing" d "it is used to prevent throboembolism" e "it is used to provide short term amnesic effects"
a "it is used to promote sleep" b "it is used to reduce anxiety" e "it is used to provide short term amnesic effects"
which actions would the nurse perform for a patient who got partial thickness burns on their hands and chest? a assess for inhalation injury b humidify 100% oxygen via non rebreather c avoid dry dressings for the wounds d assess airway, breathing, and circ e avoid mech vent for 24 hours
a assess for inhalation injury b humidify 100% oxygen via non rebreather d assess airway, breathing, and circ
which nursing interventions are appropriate for providing enternal feeding to a patient that is intubated and has burns for more than 5%v TBSA? a check gastric residuals frequently b assess bowel sounds q 8 h c determine ng tube placement d begin feedings slowly at rate of 10-20 ml/hr e increase the feedings to a goal rate within 24-48 hours
a check gastric residuals frequently b assess bowel sounds q 8 h c determine ng tube placement e increase the feedings to a goal rate within 24-48 hours enternal feedings should be started at 20-40 ml/hr
which cardiac parameters would the nurse assess to determine the adequacy of fluid resus in a burn patient? a heart rate less than 120 b manual syst bp greater than 90 c arterial syst bp greater than 90 d manual map greater than 65 e arterial line map greater than 65
a heart rate less than 120 c arterial syst bp greater than 90 e arterial line map greater than 65 manuals invalid bc of edema and vasoconstriction
which complications should the nurse assess for in a patient with metabolic asphyxiation? a hypoxia b cadiac standstill c protein hydrolysis d hydrogen cyanide posioning e ARDS
a hypoxia d hydrogen cyanide posioning metabolic asphyxiation is a type of smoke inhalation with inhalation of co or hydrogen cyanide. cardiac standstill occurs with electrical burn protein hydro occurs with chemical burn
nurse is teaching about immediate actions to be taken if the burns are more than 10% TBSA. which reason would the nurse teach to avoid using ice on burned body part? a ice can cause hypothermia b ice can cause vasoconstriction c ice can stop further tissue damage d ice can reduce bloodflow to burned area e ice can increase bloodflow to burned area
a ice can cause hypothermia b ice can cause vasoconstriction d ice can reduce bloodflow to burned area delays wound healing
what patho changes would the nurse anticipate when caring for a burn patient? select all that apply a increased viscosity b decreased hematocrit c decreased blood volume d increased vascular permeability e decreased peripheral resistance
a increased viscosity c decreased blood volume d increased vascular permeability hematocrit and peripheral resistance are increased.
a patient with burns needs permanent skin grafts , which type of grafts should be considered? a integra b alloderm c autograft d homograft e heterograft
a integra b alloderm c autograft integra is harvested from bovine cartilage. alloderm from a matrix of donated human skin. autograft is from the patients own skin. homo from cadaver and only good for 3 days-2 wks hetero from porcine skin only good for 3 days-2 wks
while assessing a burn patient, the nurse suspects hypokalemia. which causes would the nurse evaluate? a vomiting b renal failure c adrenal insufficency d iv therapy without k e prolonged gi suctioning
a vomiting d iv therapy without k e prolonged gi suctioning renal failure and adrenal insufficency are causes of hyperkalemia.
what precautions would the nurse take when providing wound care for a burn patient? a wears PPE b wears the same gown and mask for all the patients they have c uses nonsterile gloves when applying ointments d uses sterile gloves when applying sterile dressings e uses nonsterile gloves when removing contaminated dressings
a wears PPE d uses sterile gloves when applying sterile dressings e uses nonsterile gloves when removing contaminated dressings
a burn patient has not receive any active tetanus immunizations within the previous 12 years. which primary nursing measure will prevent the development of tetanus in the patient? a administer tetanus toxoid b administer tetanus immunoglobulin
b administer tetanus immunoglobulin bc they haven't had it in 12 years. if they did have it within those 10 years, then you'd give the toxoid.
teaching a group of parents how to reduce the risk of scalding and inhalation burns. which statement needs further teaching? a i should set the hot water heater to 120 f b i should light candles near an open window c i should use only hard wired smoke detectors d i should check the water temp with the back of my hand
b i should light candles near an open window water heater should be set to no more than 120 f. hard wire smoke detectors do not require batteries so that's more safe.
which clinical manifest would the nurse observe in a patient during the emergent phase of burn injury? select all that apply a increased appetite b increase heart rate c increase urine output d decreased resp rate e decreased blood pressure
b increase heart rate e decreased blood pressure other manifest are loss of ap, teachypnea, and decreased urine output
what types of food or drink would you give to a burn patient in a hypermetabolic state? a tea b milkshakes c protein powder d low protein food e high caloric food
b milkshakes c protein powder e high caloric food
what patients are at risk for developing a venous thromboembolism? a young age b obesity c prolonged mobility d upper extremity burns
b obesity c prolonged mobility
which nutritional intervention would the nurse use for an intubated patient? a start TPN b provide eternal tube starting at 20 ml/hr c feed atleast 1500 calories per day in small frequent meals d provide bolus eternal tube feedings 4 times a day
b provide eternal tube starting at 20 ml/hr
which clinical manifestation would the nurse anticipate when caring for a patient with 2nd degree burns? a blanching b red shiny vesicles c white waxy skin d severe pain e mild to mod edema
b red shiny vesicle d severe pain e mild to mod edema
assessing a patient after the inhalation of toxic chemicals. which finding indicates a lower airway injury? a blisters b singed nasal hairs c total airway obstruction d substernal retractions
b singed nasal hairs
which clinical manifestation would the nurse anticipate when caring for a patient with 3rd degree burns? a erythema b fluid filled vesicles c hard leathery skin d insensitive to pain e mild to mod edema
c hard leathery skin d insensitive to pain erythema in 1st degree fluid filled vesicles with mild to mod edema is 2nd degree.
following stable fluid resus, which would indicate that the patient is in stable condition? a urine output 0.5 ml/kg/hr b heart rate more than 120 c syst bp more than 90 d map less than 65
c syst bp more than 90
which type of burn injury would the nurse identify going through subq fat, muscle, and deeper structures?
full thickness
Which patient should the nurse prepare to transfer to a regional burn center? A 25-yr-old pregnant patient with a carboxyhemoglobin level of 1.5% A 39-yr-old patient with a partial-thickness burn to the right upper arm A 53-yr-old patient with a chemical burn to the anterior chest and neck A 42-yr-old patient who is scheduled for skin grafting of a burn wound
A 53-yr-old patient with a chemical burn to the anterior chest and neck The American Burn Association (ABA) has established referral criteria to determine which burn injuries should be treated in burn centers where specialized facilities and personnel are available to manage this type of trauma. Patients with chemical burns should be referred to a burn center. A normal serum carboxyhemoglobin level for nonsmokers is 0% to 1.5% and for smokers is 4% to 9%. Skin grafting for burn wound management is not a criterion for a referral to a burn center. Partial-thickness burns greater than 10% total body surface area (TBSA) should be referred to a burn center. A burn to the right upper arm is 4% TBSA.
When teaching the patient in the rehabilitation phase of a severe burn about performing range of motion (ROM), what explanations should the nurse give to the patient? (Select all that apply.) The exercises are the only way to prevent contractures. Active and passive ROM maintains function of body parts. ROM will reassure the patient that movement is still possible. Movement promotes mobilization of interstitial fluid back into the vascular bed. Active and passive ROM can only be done while the dressings are being changed.
Active and passive ROM maintains function of body parts. ROM will reassure the patient that movement is still possible. Movement promotes mobilization of interstitial fluid back into the vascular bed. Active and passive ROM maintains function of body parts and reassures the patient that movement is still possible are the explanations that should be used. Contractures are prevented with ROM and splints. Movement facilitates mobilization of fluid in interstitial fluid back into the vascular bed. Although it is good to collaborate with physical therapy to perform ROM during dressing changes because the patient has already taken analgesics, ROM can and should be done throughout the day.
The nurse is providing emergent care for a patient with a possible inhalation injury sustained in a house fire. The patient is anxious and disoriented, and the skin is a cherry red color. What is the priority action by the nurse? Administer 100% humidified oxygen. Teach the patient deep breathing exercises. Encourage the patient to express his feelings. Assist the patient to a high Fowler's position.
Administer 100% humidified oxygen. Carbon monoxide (CO) poisoning may occur in house fires. CO displaces oxygen on the hemoglobin molecule resulting in hypoxia. High levels of CO in the blood result in a skin color that is described as cherry red. Hypoxia may cause anxious behaviors and altered mental status. Emergency treatment for inhalation injury and CO poisoning includes the immediate administration of 100% humidified oxygen. The other interventions are appropriate for inhalation injury but are not as urgent as oxygen administration.
The nurse is caring for a patient with partial- and full-thickness burns to 65% of the body. When planning nutritional interventions for this patient, what dietary choices should the nurse implement? Full liquids only Whatever the patient requests High-protein and low-sodium foods High-calorie and high-protein foods
High-calorie and high-protein foods A hypermetabolic state occurs proportional to the size of the burn area. Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. Caloric needs are often in the 5000-kcal range. Failure to supply adequate calories and protein leads to malnutrition and delayed healing.
The nurse is caring for a patient with superficial partial-thickness burns of the face sustained within the last 12 hours. Upon assessment the nurse would expect to find which manifestation? Blisters Reddening of the skin Destruction of all skin layers Damage to sebaceous glands
Reddening of the skin The clinical appearance of superficial partial-thickness burns includes reddening of the skin, blanching with pressure, and pain and minimal swelling with no vesicles or blistering during the first 24 hours.
A patient is admitted to the emergency department with first- and second-degree burns after being involved in a house fire. Which assessment findings would alert the nurse to the presence of an inhalation injury? (Select all that apply.) Singed nasal hair Generalized pallor Painful swallowing Increasing hoarseness Burns on the upper extremities History of being involved in a large fire Darkened oral and mucosal membranes Productive cough with black sputum
Singed nasal hair Painful swallowing History of being involved in a large fire Increasing hoarseness Darkened oral and mucosal membranes Productive cough with black sputum Reliable clues to the occurrence of inhalation injury is the presence of facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral and nasal membranes, carbonaceous sputum, history of being burned in an enclosed space, altered mental status, and dyspnea.
patient has 30% TBSA thermal injuries, which action should the nurse take first? a cover burned area in ice b immerse the area in cold water c check for patent airway, breathing, and circ d cover area with a clean cool tap water damp towel
c check for patent airway, breathing, and circ
which treatment would the nurse recognize as appropriate and in the scope of practice when caring for a patient with partial thickness second degree burns to the chest, abdomen, and thighs? a application of autografts and daily sterile dressing changes b twice weekly wound cleaning and sterile dressing changes c daily wound cleaning with debridement and and sterile dressing changes
c daily wound cleaning with debridement and and sterile dressing changes
a patient sustains second degree partial thickness burns? what layers of skin would be damaged? a epidermis only b muscle and bone c dermis and epidermis d dermis, epidermis, and sub q tissue
c dermis and epidermis
fluid and electrolyte shifts during a burn injury in the emergent phase? a movement of k into the cells b adherence of albumin to vascular walls c edema in nonburned areas(3rd space shifting) d elevated hematocrit caused by hemoconcentration e movement of na and water into interstitial fluid
c edema in nonburned areas(3rd space shifting) d elevated hematocrit caused by hemoconcentration e movement of na and water into interstitial fluid
which burn injury would the nurse identify as causing tissue anoxia? a thermal burn b chemical burn c electrical burn d inhalation injury
c electrical burn electrical burn causes tissue anoxia due to nerve damage and death.
which actions should the nurse perform in a patient who came in with hydrochloric chemical burns on hands and face? a apply ice to burned area b never wash the area c flush infected area with lots of water d remove all chemical partickes on the skin e remove all chemical containing clothing
c flush infected area with lots of water d remove all chemical partickes on the skin e remove all chemical containing clothing
which clinical manifestation would the nurse expect due to thrombosis in the capillaries of the burned tissue of a patient? a elevated heart rate b elevated hematocrit c decreased blood pressure d decreased erythrocyte count
d decreased erythrocyte count hematocrit is increased during burn injuries due to hemoconcentration as a result of fluid loss. inc hr and decr bp is hemovolemic signs.