Exam #3 (CH 62 - Mgmnt of Pts With Burn Injury)

A

5. A person suffers leg burns from spilled charcoal lighter fluid. A family member extinguishes the flames. While waiting for an ambulance, what should the burned person do? a. Have someone assist him into a bath of cool water, where he can wait for emergency personnel. b. Lie down, have someone cover him with a blanket, and cover his legs with petroleum jelly. c. Remove his burned pants so that the air can help cool the wound. d. Sit in a chair, elevate his legs, and have someone cut his pants off around the burned area.

A

6. The nurse in the emergency department receives a patient who sustained a severe burn injury. What is the priority action by the nurse in this situation? a. Establish a patent airway. b. Insert an indwelling catheter. c. Replace fluids. d. Administer pain medication.

C

2. The nurse is caring for a patient who has sustained severe burns to 50% of the body. The nurse is aware that fluid shifts during the first week of the acute phase of a burn injury cause massive cell destruction. What should the nurse report immediately when reviewing laboratory studies? a. Hypernatremia b. Hypokalemia c. Hyperkalemia d. Hypercalcemia

B

10. The nurse is planning the care of a patient with a major burn. What outcome will the nurse understand will be optimal during fluid replacement? a. A urinary output of 10 mL/hr b. A urinary output of 30 mL/hr c. A urinary output of 80 mL/hr d. A urinary output of 100 mL/hr

A, B, D

11. What are the expected findings in the fluid remobilization phase that the nurse should monitor for? (Select all that apply.) a. Hemodilution b. Increased urinary output c. Metabolic alkalosis d. Sodium deficit e. Hypoglycemia

C

12. The nurse is providing wound care for a client with burns to the lower extremities. Which topical antibacterial agent carries a side effect of leukopenia that the nurse should monitor for within 48 hours after application? a. Cerium nitrate solution b. Gentamicin sulfate c. Sulfadiazine, silver (Silvadene) d. Mafenide (Sulfamylon)

A

14. The nurse is applying an occlusive dressing to a burned foot. What position should the foot be placed in after application of the dressing? a. Adduction b. Dorsiflexion c. External rotation d. Plantar flexion

C

15. A patient will be receiving biologic dressings. The nurse understands that biologic dressings, which use skin from living or recently deceased humans, are known by what name? a. Autografts b. Heterografts c. Homografts d. Xenografts

B

16. The nurse is administering an analgesic to a patient with major burns. What is the recommended route for administration for this patient? a. Intramuscular b. Intravenous c. Oral d. Subcutaneous

C

17. To meet early nutritional demands for protein, a 198lb (90 kg) burned patient will need to ingest a minimum of how much protein every 24 hours? a. 90 g/day b. 110 g/day c. 180 g/day d. 270 g/day

D

3. What laboratory value observed by the nurse is unexpected during the fluid remobilization phase of a major burn? a. Hematocrit level of 45% b. A pH of 7.20, PaO2 of 38 mm Hg, and bicarbonate level of 15 mEq/L c. Serum potassium level of 3.2 mEq/L d. Serum sodium level of 140 mEq/L

C

4. The nurse is caring for a patient who sustained a major burn. What serious gastrointestinal disturbance should the nurse monitor for that frequently occurs with a major burn? a. Diverticulitis b. Hematemesis c. Paralytic ileus d. Ulcerative colitis

B

7. A sample consensus formula for fluid replacement recommends that a balanced salt solution be administered in the first 24 hours of a burn in the range of 2 to 4 mL/kg/% of burn, with 50% of the total given in the first 8 hours postburn. A 176-lb (80-kg) man with a 30% burn should receive a minimum of how much fluid replacement in the first 8 hours? a. 1,200 mL b. 2,400 mL c. 3,600 mL d. 4,800 mL

A, B, D

8. The nurse is monitoring for fluid and electrolyte changes in the emergent phase of burn injury for a patient. Which of the following will be an expected outcome? (Select all that apply.) a. Base-bicarbonate deficit b. Elevated hematocrit level c. Potassium deficit d. Sodium deficit e. Magnesium deficit

D

9. During the acute phase of burn injury, the nurse knows to assess for signs of potassium shifting during what time frame? a. Within 24 hours b. Between 24 and 48 hours c. At the beginning of the third day d. Beginning on day 4 or day 5

C

13. The nurse knows that which topical antibacterial agent does not penetrate eschar? a. Acticoat b. Mafenide acetate c. Silver nitrate 0.5% d. Silver sulfadiazine 1%

B

1. The nurse is caring for a patient who sustained a full-thickness burn to his arm when he was scalded with boiling water. How did the nurse determine that the patient's burns are full-thickness burns? a. Classification by the appearance of blisters b. Identification by the destruction of the dermis and epidermis c. Not associated with edema formation d. Usually very painful because of exposed nerve endings