Test 3 - Burns

Estimate the total body surface area burn injury using the rule of 9's. Burns involve the entire right arm and upper back. _____%

ANS: 18% The entire right arm burn is 9%. The upper torso is 9%. The patient has an 18% TBSA burn injury.

The nurse estimates the extent of a burn using the rule of nines for a patient who has been admitted with deep partial-thickness burns of the anterior trunk and the entire left arm. What percentage of the patient's total body surface area (TBSA) has been injured? _____________

ANS: 27% When using the rule of nines, the anterior trunk is considered to cover 18% of the patient's body and the anterior (4.5%) and posterior (4.5%) left arm equals 9%.

An 80-kg patient with burns over 30% of total body surface area (TBSA) is admitted to the burn unit. What is the IV infusion rate (mL/hour) for lactated Ringer's solution that the nurse will give during the first 8 hours?

ANS: 600 ml/hr The Parkland formula states that patients should receive 4 mL/kg/%TBSA burned during the first 24 hours. Half of the total volume is given in the first 8 hours and then the remaining half is given over 16 hours: 4 x 80 x 30 = 9600 mL total volume; 9600/2 = 4800 mL in the first 8 hours; 4800 mL/8 hr = 600 mL/hr.

A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first? a. Auscultate the patients lung sounds. b. Determine the extent and depth of the burns. c. Infuse the ordered lactated Ringers solution. d. Administer the ordered hydromorphone (Dilaudid).

ANS: A A patient with facial and chest burns is at risk for inhalation injury, and assessment of airway and breathing is the priority. The other actions will be completed after airway management is assured.

Which patient is most appropriate for the burn unit charge nurse to assign to a registered nurse (RN) who has floated from the hospital medical unit? a. A 34-year-old patient who has a weight loss of 15% from admission and requires enteral feedings. b. A 67-year-old patient who has blebs under an autograft on the thigh and has an order for bleb aspiration c. A 46-year-old patient who has just come back to the unit after having a cultured epithelial autograft to the chest d. A 65-year-old patient who has twice-daily burn debridements and dressing changes to partial-thickness facial burns

ANS: A An RN from a medical unit would be familiar with malnutrition and with administration and evaluation of response to enteral feedings. The other patients require burn assessment and care that is more appropriate for staff who regularly care for burned patients.

A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain adequate nutrition, the nurse should plan to take which action? a. Insert a feeding tube and initiate enteral feedings. b. Infuse total parenteral nutrition via a central catheter. c. Encourage an oral intake of at least 5000 kcal per day. d. Administer multiple vitamins and minerals in the IV solution.

ANS: A Enteral feedings can usually be initiated during the emergent phase at low rates and increased over 24 to 48 hours to the goal rate. During the emergent phase, the patient will be unable to eat enough calories to meet nutritional needs and may have a paralytic ileus that prevents adequate nutrient absorption. Vitamins and minerals may be administered during the emergent phase, but these will not assist in meeting the patients caloric needs. Parenteral nutrition increases the infection risk, does not help preserve gastrointestinal function, and is not routinely used in burn patients.

The charge nurse observes the following actions being taken by a new nurse on the burn unit. Which action by the new nurse would require immediate intervention by the charge nurse? a. The new nurse uses clean gloves when applying antibacterial cream to a burn wound. b. The new nurse obtains burn cultures when the patient has a temperature of 95.2 F (35.1 C). c. The new nurse gives PRN fentanyl (Sublimaze) IV to a patient 5 minutes before a dressing change. d. The new nurse calls the health care provider when a nondiabetic patient's serum glucose is elevated.

ANS: A Sterile gloves would be worn when applying medications or dressings to a burn. Hypothermia is an indicator of possible sepsis, and cultures are appropriate. Nondiabetic patients may need insulin because stress and high-calorie intake may lead to temporary hyperglycemia. Fentanyl peaks 5 minutes after IV administration and would be used just before and during dressing changes for pain management. Page 442 11th edition When the patient's open burn wounds are exposed, always wear personal protective equipment (PPE) (e.g., disposable hats, masks, gowns, gloves). When removing contaminated dressings and washing wounds, use nonsterile, disposable gloves. Use sterile gloves when applying ointments and sterile dressings. In addition, prevent shivering by keeping the room warm (around 85°F [29.4°C]). Before leaving one patient, remove your PPE and wash your hands. Don new PPE before you treat another patient.

To maintain a positive nitrogen balance in a major burn, the patient must a. eat a high-protein, high-carbohydrate diet. b. increase normal caloric intake by about four times. c. eat at least 1500 calories/day in small, frequent meals. d. eat a gluten-free diet for the chemical effect on nitrogen balance.

ANS: a The patient should be encouraged to eat high-protein, high-carbohydrate foods to meet increased caloric needs. Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. Failure to supply adequate calories and protein leads to malnutrition and delays in healing.

A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take? a. Notify the health care provider. b. Monitor the pulses every 2 hours. c. Elevate both legs above heart level with pillows. d. Encourage the patient to flex and extend the toes on both feet.

ANS: A The decrease in pulse in a patient with circumferential burns indicates decreased circulation to the legs and the need for an escharotomy. Monitoring the pulses is not an adequate response to the decrease in circulation. Elevating the legs or increasing toe movement will not improve the patients circulation. Page 500 12th ed Cardiovascular Other complications can affect perfusion besides burn shock. Deep circumferential burns and subsequent edema formation can impair blood flow to the extremities. If untreated, ischemia, paresthesia, and necrosis can occur. An escharotomy (an incision through the full-thickness eschar) will restore circulation to compromised extremities or improve chest expansion (Fig. 26.8).8 HCPs perform this procedure.

The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine output has dramatically increased. Which action by the nurse would best ensure adequate kidney function? a. Continue to monitor the urine output. b. Monitor for increased white blood cells (WBCs). c. Assess that blisters and edema have subsided. d. Prepare the patient for discharge from the burn unit.

ANS: A The patients urine output indicates that the patient is entering the acute phase of the burn injury and moving on from the emergent stage. At the end of the emergent phase, capillary permeability normalizes and the patient begins to diurese large amounts of urine with a low specific gravity. Although this may occur at about 48 hours, it may be longer in some patients. Blisters and edema begin to resolve, but this process requires more time. White blood cells may increase or decrease, based on the patients immune status and any infectious processes. The WBC count does not indicate kidney function. The patient will likely remain in the burn unit during the acute stage of burn injury.

An employee spills industrial acids on both arms and legs at work. What is the priority action that the occupational health nurse at the facility should take? a. Remove nonadherent clothing and watch. b. Apply an alkaline solution to the affected area. c. Place cool compresses on the area of exposure. d. Cover the affected area with dry, sterile dressings.

ANS: A With chemical burns, the initial action is to remove the chemical from contact with the skin as quickly as possible. Remove nonadherent clothing, shoes, watches, jewelry, glasses, or contact lenses (if face was exposed). Flush chemical from wound and surrounding area with copious amounts of saline solution or water. Covering the affected area or placing cool compresses on the area will leave the chemical in contact with the skin. Application of an alkaline solution is not recommended. Page 495 Chemical Burns Contact with acids, alkalines, or organic compounds can cause chemical burns through absorption, inhalation, or ingestion. Dangerous chemicals are in homes, businesses, and industries. For example, severe injury can occur with exposure to lye and sulfuric acid, common chemicals used to unclog sinks in homes. Exposure to wet cement, oven cleaners, and heavy industrial cleaners can cause chemical burns. Chemicals such as phenols (chemical disinfectants) and petroleum products (creosote and gasoline) cause not only external burns but also systemic toxicity. Acid chemicals cause tissue necrosis. Alkaline chemicals cause liquefaction necrosis, which can be more damaging. Some chemicals will have heat-producing reactions once exposed to the skin, causing superficial blisters or even deep burns.

A nurse in a provider's office is assessing a client who has a severe sunburn. Which of the following classifications should the nurse use to document this burn? A. Superficial thickness B. Superficial partial thickness C. Deep partial thickness D. Full thickness

ANS: A A. sunburn is a superficial thickness burn. Superficial burns damage the top layer of the skin. B. A superficial partial thickness burn results from fames or scalds. This damages the entire epidermis layer of the skin. C. A deep partial thickness burn can result from contact with hot grease. This afects the deep layers of the skin. D. A full thickness burn can result from contact with hot tar. This afects the dermis and sometimes the subcutaneous fat ‐ layer.

A nurse is assessing a client who sustained deep partial thickness and full thickness burns over 40% of his body 24 hr ago. Which of the following are findings should the nurse expect? (Select all that apply.) A. Temperature 36.1 C (97 F) B. Bradycardia C. Hyperkalemia D. Hyponatremia E. Decreased hematocrit

ANS: A, C, D A. CORRECT: Decreased temperature can occur in the first few hours following a burn, because the body's ability to regulate temperature is compromised B. Tachycardia not bradycardia occurs during the initial phase following a burn due to sympathetic nervous system compensation. C. CORRECT: Hyperkalemia occurs during the initial phase following a burn as a result of leakage of fluid from the intracellular space. D. CORRECT: Hyponatremia occurs during the initial phase of a burn as a result in sodium retention in the interstitial space. E. Hct increases not decreases during the initial phase of a burn due to hemoconcentration.

Which action will the nurse include in the plan of care for a patient in the rehabilitation phase after a burn injury to the right arm and chest? a. Keep the arms in a position of comfort. b. Apply water-based cream to healing areas. c. Avoid the use of sustained-release opioids. d. Teach about the purpose of tetanus immunization.

ANS: B Application of water-based emollients will moisturize new skin and decrease flakiness and itching. To avoid contractures, the joints of the right arm should be positioned in an extended position, which is not the position of comfort. Patients may need to continue the use of opioids during rehabilitation. Tetanus immunization would have been given during the emergent phase of the burn injury.

A patient admitted with burns over 30% of the body surface 3 days ago has dramatically increased urine output today. How would the nurse interpret this finding? a. Diuresis indicates development of acute kidney injury. b. Diuresis reflects normalizing capillary permeability. c. Increased urine volume signals a likely urinary infection. d. Increased urine volume requires increased calorie intake.

ANS: B At the end of the emergent phase, capillary permeability normalizes, and the patient begins to diurese large amounts of urine with a low specific gravity. This usually happens about 72 hours after the initial injury. A low urine output in the early days after a burn injury would raise concern for possible kidney injury form hypovolemia. Patients with burns are susceptible to infection and may need additional calories for wound healing, however, increased urine volume is not associated with a urinary tract infection or a need for additional calories.

A patient is admitted with burns to the head, face, and hands. Initially, wheezes are heard throughout the chest, but an hour later, the lung sounds are decreased, and no wheezes are audible. Which action would the nurse take? a. Encourage the patient to cough and auscultate the lungs again. b. Notify the health care provider and prepare for endotracheal intubation. c. Document the assessment and continue to monitor the patient's respiratory rate. d. Reposition the patient in high-Fowler's position and reassess breath sounds.

ANS: B The patients history and clinical manifestations suggest airway edema and the health care provider should be notified immediately, so that intubation can be done rapidly. Placing the patient in a more upright position or having the patient cough will not address the problem of airway edema. Continuing to monitor is inappropriate because immediate action should occur.

A nurse is caring for a patient who has burns of the ears, head, neck, and right arm and hand. The nurse should place the patient in which position? a. Place the right arm and hand flexed in a position of comfort. b. Elevate the right arm and hand on pillows and extend the fingers. c. Assist the patient to a supine position with a small pillow under the head. d. Position the patient in a side-lying position with rolled towel under the neck.

ANS: B The right hand and arm should be elevated to reduce swelling and the fingers extended to avoid flexion contractures (even though this position may not be comfortable for the patient). The patient with burns of the ears should not use a pillow for the head because this will put pressure on the ears, and the pillow may stick to the ears. Patients with neck burns should not use a pillow because the head should be maintained in an extended position in order to avoid contractures.

A young adult patient who is in the rehabilitation phase 6 months after a severe face and neck burn tells the nurse, "I'm sorry that I'm still alive. My life will never be normal again." Which response should the nurse provide? a. "Most people recover after a burn and feel satisfied with their lives." b. "It's true that your life may be different. What concerns you the most?" c. "Why do you feel that way? It will get better as your recovery progresses." d. "It is really too early to know how much your life will be changed by the burn."

ANS: B This response acknowledges the patient's feelings and asks for more assessment data that will help in developing an appropriate plan of care to assist the patient with the emotional response to the burn injury. the other statements do not acknowledge what the patient is expressing.

While the patients full thickness burn wounds to the face are exposed, what is the best nursing action to prevent cross contamination? OR Which nursing action prevents cross contamination when the patient's full-thickness burn wounds are exposed? a. Use sterile gloves when removing old dressings. b. Wear gowns, caps, masks, and gloves during all care of the patient. c. Administer IV antibiotics to prevent bacterial colonization of wounds. d. Turn the room temperature up to at least 70 F (20 C) during dressing changes.

ANS: B Use of gowns, caps, masks, and gloves during all patient care will decrease the possibility of wound contamination for a patient whose burns are not covered. When removing contaminated dressings and washing the dirty wound, use nonsterile, disposable gloves. The room temperature should be kept at approximately 85 F for patients with open burn wounds to prevent shivering. Systemic antibiotics are not well absorbed into deep burns because of the lack of circulation. 11th edition Page 442 Wound Care Infection can cause further tissue injury and possible sepsis. The source of infection in burn wounds is likely the patient's own flora, mostly from the skin, respiratory, and gastrointestinal (GI) systems. Two approaches to burn wound treatment are (1) the open method and (2) the use of multiple dressing changes (closed method). In the open method the patient's burn is covered with a topical antimicrobial and has no dressing over the wound. This approach is usually limited to the care of facial burns. In the multiple dressing change, or closed method, sterile gauze dressings are impregnated with or laid over a topical antimicrobial (Fig. 24.11). These dressings are changed from every 12 hours to once every 14 days depending on the product. Most burn centers use the closed technique. When the patient's open burn wounds are exposed, always wear personal protective equipment (PPE) (e.g., disposable hats, masks, gowns, gloves). When removing contaminated dressings and washing wounds, use nonsterile, disposable gloves. Use sterile gloves when applying ointments and sterile dressings. In addition, prevent shivering by keeping the room warm (around 85°F [29.4°C]). Before leaving one patient, remove your PPE and wash your hands. Don new PPE before you treat another patient.

Which patient would the nurse assess first? a. A patient with burns who reports level 8 (0 to 10 scale) pain b. A patient with smoke inhalation who has wheezes and confusion c. A patient with full-thickness leg burns who is scheduled for a dressing change d. A patient with partial thickness burns who is receiving IV fluids at 500 mL/hr

ANS: B Wheezes and confusion are evidence of lower airway injury. the patient should be assessed at once to determine the need for O2 or intubation (or both). The other patients should be assessed as rapidly as possible, but they do not have evidence of life-threatening complications.

When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes dry, pale, and hard skin. The patient states that the burn is not painful. Which term would the nurse use to document the burn depth? a. First-degree skin destruction b. Full-thickness skin destruction c. Deep partial-thickness skin destruction d. Superficial partial-thickness skin destruction

ANS: B With full-thickness skin destruction, the appearance is pale and dry or leathery, and the area is painless because of the associated nerve destruction. Erythema, swelling, and blisters point to a deep partial-thickness burn. With superficial partial-thickness burns, the area is red, but no blisters are present. First-degree burns exhibit erythema, blanching, and pain.

A patient with burns covering 40% total body surface area (TBSA) is in the acute phase of burn treatment. Which snack would be best for the nurse to offer to this patient? a. Bananas b. Orange gelatin c. Vanilla milkshake d. Whole grain bagel

ANS: C A patient with a burn injury needs high protein and calorie food intake, and the milkshake is the highest in these nutrients. The other choices are not as nutrient-dense as the milkshake. Gelatin is likely high in sugar. The bagel is a good carbohydrate choice, but low in protein. Bananas are a good source of potassium, but are not high in protein and calories.

Which instruction would the nurse provide to prevent burn injuries? OR Which prevention strategy would the nurse include when teaching about home fire safety? a. Set hot water temperature at 140°F. b. Use only hardwired smoke detectors. c. Encourage regular home fire exit drills. d. Do not allow older adults to cook unattended.

ANS: C A risk-reduction strategy for household fires is to encourage regular home fire exit drills. Water heaters set at 120° F (60° C) or higher are a burn hazard in the home; the temperature should be set at less than 120° F (40° C). Installation of smoke and carbon monoxide detectors can prevent inhalation injuries. Hard-wired smoke detectors do not require battery replacement; battery-operated smoke detectors may be used. Supervision of older adults who are cooking is necessary if cognitive impairment is present.

A nurse is caring for a client who has sustained burns over 35% of total body surface area. The client's voice becomes hoarse, a brassy cough has developed, and the client is drooling. The nurse should identify these findings as indications that the client has which of the following? A. Pulmonary edema B. Bacterial pneumonia C. Inhalation injury D. Carbon monoxide poisoning

ANS: C A. Difficulty breathing and production of pink frothy sputum indicate pulmonary edema. B. Productive cough and a fever are indicative of a bacterial infection. C. CORRECT: Wheezing and hoarseness indicate inhalation injury with impending loss of the airway. These require immediate reporting to the provider. D. Confusion and headaches indicate carbon monoxide poisoning.

A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first? a. Assess oral temperature. b. Check a potassium level. c. Place on cardiac monitor. d. Assess for pain at contact points.

ANS: C After an electrical burn, the patient is at risk for fatal dysrhythmias and should be placed on a cardiac monitor. Assessing the oral temperature is not as important as assessing for cardiac dysrhythmias. Checking the potassium level is important. However, it will take time before the laboratory results are back. The first intervention is to place the patient on a cardiac monitor and assess for dysrhythmias, so that they can be treated if occurring. A decreased or increased potassium level will alert the nurse to the possibility of dysrhythmias. The cardiac monitor will alert the nurse immediately of any dysrhythmias. Assessing for pain is important, but the patient can endure pain until the cardiac monitor is attached. Cardiac dysrhythmias can be lethal.

A patient has just arrived in the emergency department after an electrical burn from exposure to a high-voltage current. What is the priority nursing assessment? a. Oral temperature b. Peripheral pulses c. Extremity movement d. Pupil reaction to light

ANS: C All patients with electrical burns should be considered at risk for cervical spine injury, and assessments of extremity movement will provide baseline data. The other assessment data are also necessary but not as essential as determining the cervical spine status. Page 495 12th ed Electrical Burns Electrical burns result from the intense heat generated from an electric current. Direct damage to nerves and vessels can cause tissue anoxia and cell death. The severity of an electrical injury depends on the voltage, tissue resistance, current pathways, surface area in contact with the current, and length of time that the current flow was sustained (Fig. 26.1). Current that passes through vital organs (e.g., brain, heart, kidneys) causes more life-threatening sequela when compared to a current passing through other tissues. The severity of an electrical injury can be hard to determine initially since most of the damage is below the skin. Contact with an electric current can cause muscle contractions strong enough to fracture the long bones and vertebrae. Forceful propulsion of the body from an electrical source can cause injuries such as spinal and limb fractures. For this reason, consider cervical spine injury for all patients with electrical burns. Electrical injury puts the patient at risk for respiratory arrest, severe metabolic acidosis, and myoglobinuria. An electric shock can cause immediate cardiac standstill or ventricular fibrillation. Massive muscle and blood vessel damage can release myoglobin from injured muscle and hemoglobin from damaged red blood cells (RBCs). Myoglobin can block the renal tubules resulting in acute kidney injury (AKI; see Chapter 51).

Which nursing action is a priority for a patient who had a burn injury while working on an electrical power line? a. Inspect the contact burns. b. Check the blood pressure. c. Stabilize the cervical spine. d. Assess alertness and orientation.

ANS: C Cervical spine injuries are often associated with electrical burns. Therefore, stabilization of the cervical spine takes precedence after airway management. the other actions are also included in the emergent care after electrical burns, but the most important action is to avoid further spinal cord injury.

A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be administered in the first 24 hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids? a. 350 mL/hour b. 523 mL/hour c. 938 mL/hour d. 1250 mL/hour

ANS: C Half of the fluid replacement using the Parkland formula is administered in the first 8 hours and the other half over the next 16 hours. In this case, the patient should receive half of the initial rate, or 938 mL/hr.

The nurse is reviewing laboratory results on a patient who had a large burn 48 hours ago. Which result requires priority action by the nurse? a. Hematocrit 53% b. Serum sodium 147 mEq/L c. Serum potassium 6.1 mEq/L d. Blood urea nitrogen 37 mg/dL

ANS: C Hyperkalemia can lead to fatal dysrhythmias and indicates that the patient requires cardiac monitoring and immediate treatment to lower the potassium level. The other laboratory values are also abnormal and require changes in treatment, but they are not as immediately life threatening as the elevated potassium level.

The patient received a cultured epithelial autograft (CEA) to the entire left leg. What would the nurse include when planning discharge teaching? a. Sit or lie in the position of comfort. b. Wear a pressure garment for 8 hours each day. c. Refer the patient to a counselor for psychosocial support. d. Use the sun to increase the skin color on the healed areas.

ANS: C 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

What nutrition intervention may promote wound healing for a patient with a 10% burn injury? a. Eat a high-protein, high-carbohydrate diet b. Increase normal caloric intake by about 4 times c. Eat at least 1500 calories/day in small, frequent meals d. Eat a lactose-free diet to reduce the potential for diarrhea

ANS: a The patient should be encouraged to eat high-protein, high-carbohydrate foods to meet increased caloric needs. Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. Failure to supply adequate calories and protein leads to malnutrition and delays in healing. Caloric needs will exceed 1500 calories/day. A dietitian will calculate the number of calories needed based on % burn and other individual factors. Patients with burns over 20% TBSA may need tube feed.

On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which prescribed action would be the nurse's priority? a. Monitoring urine output b. Scheduling additional laboratory tests c. Increasing the rate of the ordered IV solution d. Typing and crossmatching for a blood transfusion

ANS: C The patient's laboratory results show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Additional lab tests can be scheduled after the fluid volume is increased. Because the hematocrit and hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase once the patient's fluid balance has been restored. Urine output would be monitored frequently, likely every hour, and adequate fluid volume will be needed to maintain the urine output.

A young female patient with deep partial-thickness face and neck burns is in the rehabilitation phase. Which statement by the patient indicates that a problem with body image is resolving? a. "I'm glad to know the scars will be gone soon." b. "I don't use a pillow, so my neck will be OK." c. "I think dark beige makeup will cover this scar." d. "I don't think my boyfriend will want to look at me now."

ANS: C The willingness to use strategies to enhance appearance is an indication that the disturbed body image is resolving. Expressing concern about the appearance to others shows a willingness to discuss appearance but not resolution of the problem. Because deep partial-thickness burns leave permanent scars, a statement that the scars are temporary shows denial rather than resolution of the problem. Avoiding using a pillow will help prevent contractures, but it does not address the problem of disturbed body image.

The nurse is caring for a patient with partial- and full-thickness burns to 65% of the body. When planning nutrition interventions for the patient, what diet would the nurse implement? a. Full liquids only b. Whatever the patient requests c. High-protein and low-sodium foods d. High-calorie and high-protein foods

ANS: D 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.

A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital. Which action should the nurse take first? a. Stay at the bedside and reassure the patient. b. Administer the ordered morphine sulfate IV. c. Assess orientation and level of consciousness. d. Use pulse oximetry to check the oxygen saturation.

ANS: D Agitation in a patient who may have suffered inhalation injury might indicate hypoxia, and this should be assessed by the nurse first. Administration of morphine may be indicated if the nurse determines that the agitation is caused by pain. Assessing level of consciousness and orientation is also appropriate but not as essential as determining whether the patient is hypoxemic. Reassurance is not helpful to reduce agitation in a hypoxemic patient.

Esomeprazole (Nexium) is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which nursing assessment would best evaluate the effectiveness of the medication? a. Bowel sounds b. Stool frequency c. Abdominal distention d. Stools for occult blood

ANS: D H2 blockers and proton pump inhibitors are given to prevent Curlings ulcer in the patient who has suffered burn injuries. Proton pump inhibitors usually do not affect bowel sounds, stool frequency, or appetite. Page 505 12 th ed Gastrointestinal The GI system may develop complications during this phase. Diarrhea may result from the use of EN or antibiotics. Constipation can occur as a side effect of opioids, decreased mobility, and a low-fiber diet. Curling ulcer is a type of gastroduodenal ulcer characterized by diffuse superficial lesions (including mucosal erosion). The stress response can decrease blood flow to the GI tract. Aim to prevent Curling ulcer by feeding the patient as soon as possible after the burn injury. Antacids, H2-histamine blockers (e.g., cimetidine), and proton pump inhibitors (e.g., omeprazole) are used prophylactically to neutralize stomach acids and inhibit histamine and the secretion of hydrochloric acid (Table 26.8). Patients with major burns may have occult blood in their stools during the acute phase and require close monitoring for bleeding.

The nurse is reviewing the medication administration record (MAR) on a patient with partial-thickness burns. Which medication is best for the nurse to administer before scheduled wound debridement? a. Ketorolac (Toradol) b. Lorazepam (Ativan) c. Gabapentin (Neurontin) d. Hydromorphone (Dilaudid)

ANS: D Opioid pain medications are the best choice for pain control. The other medications are used as adjuvants to enhance the effects of opioids. Page 507 12th ed Burn patients have 2 kinds of pain: (1) continuous, background pain that might be present throughout the day and night, and (2) treatment-induced pain caused by dressing changes, ambulation, and rehabilitation activities. The first line of treatment is medication (Table 26.8). With background pain, frequent IV administration of an opioid (e.g., hydromorphone) provides a steady, therapeutic level of the drug. If tolerating food, slow-release, twice-daily opioids (e.g., morphine) can be used. Patient-controlled analgesia (PCA) is used in some burn centers. Anxiolytics (e.g., lorazepam, midazolam) and adjuvant analgesics (e.g., gabapentin, pregabalin) can enhance opioid effectiveness. Their use can help reduce opioid dosage and undesirable side effects.

A patient who was found unconscious in a burning house is brought to the emergency department by ambulance. The nurse notes that the patients skin color is bright red. Which action should the nurse take first? a. Insert two large-bore IV lines. b. Check the patients orientation. c. Assess for singed nasal hair and dark oral mucous membranes. d. Place the patient on 100% oxygen using a non-rebreather mask.

ANS: D The patients history and skin color suggest carbon monoxide poisoning, which should be treated by rapidly starting oxygen at 100%. The other actions can be taken after the action to correct gas exchange.

Eight hours after a thermal burn covering 50% of a patients total body surface area (TBSA) the nurse assesses the patient. Which information would be a priority to communicate to the health care provider? a. Blood pressure is 95/48 per arterial line. b. Serous exudate is leaking from the burns. c. Cardiac monitor shows a pulse rate of 108. d. Urine output is 20 mL per hour for the past 2 hours.

ANS: D The urine output should be at least 0.5 to 1.0 mL/kg/hr during the emergent phase, when the patient is at great risk for hypovolemic shock. The nurse should notify the health care provider because a higher IV fluid rate is needed. BP during the emergent phase should be greater than 90 systolic, and the pulse rate should be less than 120. Serous exudate from the burns is expected during the emergent phase. Page 502 Fluid Therapy Assess for the adequacy of fluid resuscitation hourly using urine output and cardiac parameters: • Urine output for adults: 0.5 to 1 mL/kg/hr; for children: 1 to 1.5 mg/kg/hr. • Cardiac parameters: Mean arterial pressure (MAP) greater than 65 mm Hg, systolic BP greater than 90 mm Hg, heart rate less than 120 beats/min. MAP and BP are best measured by an arterial line. Manual BP measurement is often invalid because of edema and vasoconstriction.

During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion? a. Check skin turgor. b. Monitor daily weight. c. Assess mucous membranes. d. Measure hourly urine output.

ANS: D When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hour. The patients weight is not useful in this situation because of the effects of third spacing and evaporative fluid loss. Mucous membrane assessment and skin turgor also may be used, but they are not as adequate in determining that fluid infusions are maintaining adequate perfusion. Page 502 Fluid Therapy Assess for the adequacy of fluid resuscitation hourly using urine output and cardiac parameters: • Urine output for adults: 0.5 to 1 mL/kg/hr; for children: 1 to 1.5 mg/kg/hr. • Cardiac parameters: Mean arterial pressure (MAP) greater than 65 mm Hg, systolic BP greater than 90 mm Hg, heart rate less than 120 beats/min. MAP and BP are best measured by an arterial line. Manual BP measurement is often invalid because of edema and vasoconstriction.

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? a. Tachycardia b. Restlessness c. Hypokalemia d. Gastrointestinal (GI) distress

ANS: a 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 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? a. Administer 100% humidified oxygen. b. Teach the patient deep breathing exercises. c. Encourage the patient to express his feelings. d. Assist the patient to a high Fowler's position.

ANS: a 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 planning to change the dressing that covers a deep partial-thickness burn of the right lower leg. Which prescribed medication would the nurse administer to the patient 30 minutes before the scheduled dressing change? a. Morphine b. Sertraline c. Zolpidem d. Alprazolam

ANS: a 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.

The injury that is least likely to result in a full-thickness burn is a. sunburn. b. scald injury. c. chemical burn. d. electrical injury.

ANS: a Full-thickness burns may be caused by contact with flames, scalding liquids, chemicals, tar, or electrical current.

Which lab result supports the need for additional IV fluid to treat burn shock? a. Hematocrit 52% b. Sodium 137 mEq/L c. WBC 12.5 × 109/L d. Potassium 3.4 mmol/L

ANS: a Hematocrit is the ratio of the volume of red blood cells (RBC) to the total volume of blood. An increase in hematocrit indicates a higher ratio of RBCs. Additional IV fluids are needed to reduce the hematocrit to normal. Elevated WBCs indicate inflammation or early infection. Sodium and potassium labs are within normal ranges.

A patient is hospitalized with burns to his head, neck, and anterior and posterior chest after an explosion in his garage. The respiratory therapist applied a non-rebreather mask. On assessment, the nurse auscultates wheezes throughout the lung fields. On reassessment, the wheezes are gone, and the breath sounds are greatly decreased. Respiratory rate is 6/min. Oxygen saturation decreases to 88%. The patient is unresponsive. What is the priority nursing intervention? a. Notify the HCP and get ready for intubation. b. Encourage the patient to cough and auscultate the lungs again. c. Obtain vital signs, oxygen saturation, and a STAT arterial blood gas. d. Document the findings and continue to monitor the patient's breathing.

ANS: a Inhalation injury results in exposure of the respiratory tract to intense heat or flames with inhalation of noxious chemicals, smoke, or carbon monoxide (CO). The nurse should anticipate the need for intubation and mechanical ventilation because this patient is demonstrating signs of severe respiratory distress.

What intervention prevents hypertrophic scarring during the rehabilitation phase of burn recovery? a. Applying pressure garments b. Repositioning the patient every 2 hours c. Performing active ROM at least every 4 hours d. Applying a water-based moisturizer to healed skin

ANS: a Pressure can help keep a scar flat and reduce hypertrophic scarring. Gentle pressure can be maintained on the healed burn with custom-fitted pressure garments.

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.) a. Urine output is 46 mL/hr. b. Heart rate is 94 beats/min. c. Urine specific gravity is 1.040. d. Mean arterial pressure is 54 mm Hg. e. Systolic blood pressure is 88 mm Hg.

ANS: a, b 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. Page 502 Fluid Therapy Monitor the patient for early signs of fluid overload, especially older patients or those with chronic heart, lung, or kidney diseases. Assess for the adequacy of fluid resuscitation hourly using urine output and cardiac parameters: • Urine output for adults: 0.5 to 1 mL/kg/hr; for children: 1 to 1.5 mg/kg/hr. • Cardiac parameters: Mean arterial pressure (MAP) greater than 65 mm Hg, systolic BP greater than 90 mm Hg, heart rate less than 120 beats/min. MAP and BP are best measured by an arterial line. Manual BP measurement is often invalid because of edema and vasoconstriction.

What nursing interventions can be used to manage burn pain? (select all that apply) a. Suggest pain management options. b. Use a pain-rating tool to monitor the patient's level of pain. c. Delay painful dressing changes until the patient's pain is completely relieved. d. Use a multimodal approach (e.g., sustained-release and short-acting opioids, NSAIDs, adjuvant analgesics). e. Provide nonpharmacologic therapies (e.g., music therapy, distraction) to replace opioids in the acute phase of a burn injury.

ANS: a, b, d The use of a pain-rating tool assists the nurse in the assessment, monitoring, and evaluation of the pain management plan. The more control the patient has in managing the pain, the more successful the chosen strategies are. Various analgesics are prescribed for pain relief. Burn pain can be both continuous and treatment-related. It is not realistic to promise a patient that pain will be eliminated or managed with only non-pharmacologic methods. Distraction, massage, relaxation are often incorporated into the pain treatment plan.

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.) a. Escharotomy b. Administration of diuretics c. IV and oral pain medications d. Daily cleansing and debridement e. Application of topical antimicrobial agent

ANS: a, c, d, e 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.

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.) a. Singed nasal hair b. Generalized pallor c. Painful swallowing d. Burns on the upper extremities e. History of being involved in a large fire

ANS: a, c, e 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.

When assessing a patient with a partial-thickness burn, the nurse would expect to find (select all that apply) a. blisters. b. exposed fascia. c. exposed muscles. d. intact nerve endings. e. red, shiny, wet appearance.

ANS: a, d, e The appearance of partial-thickness (deep) burns may include fluid-filled vesicles (blisters) that are red, shiny, or wet (if vesicles have ruptured). Patients may have severe pain caused by exposure of nerve endings and may have mild to moderate edema.

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? a. Skin is hard with a dry, waxy white appearance. b. Skin is shiny and red with clear, fluid-filled blisters. c. Skin is red and blanches when slight pressure is applied. d. Skin is leathery with visible muscles, tendons, and bones.

ANS: b 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.

The patient in the emergent phase of a burn injury is being treated for severe pain. What medication would the nurse anticipate administering to the patient? a. Subcutaneous (SQ) tetanus toxoid b. Intravenous (IV) morphine sulfate c. Intramuscular (IM) hydromorphone d. Oral oxycodone and acetaminophen

ANS: b 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.

An older adult is moving into an independent living facility. What teaching would the nurse provide to decrease the patient's risk of being accidently burned in their new home? a. Help the patient to stop smoking. b. Install tap water anti-scald devices. c. Ensure all meals are cooked for the patient. d. Be sure the patient uses an open space heater.

ANS: b 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. Page 495 12th ed Most burn accidents are preventable when safety policies are in place. Coordinated national burn prevention programs in higher-income countries have focused on child-resistant lighters, tap water anti-scald devices, stricter building codes, having smoke detectors, and burn safety education curriculums in schools.4 As a nurse, you can advocate for and teach about burn prevention strategies (Tables 26.1 and 26.2).

The nurse is planning care for the patient in the acute phase of a burn injury. After the progression from the emergent to the acute phase, what nursing action is important for the nurse to perform? a. Begin IV fluid replacement. b. Monitor for signs of complications. c. Assess and manage pain and anxiety. d. Discuss possible reconstructive surgery.

ANS: b 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 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? a. Blisters b. Reddening of the skin c. Destruction of all skin layers d. Damage to sebaceous glands

ANS: b 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 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, calculate the extent of these burns. a. 18% b, 22.5% c. 27% d. 36%

ANS: b 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.

When teaching the patient in the rehabilitation phase of a severe burn about performing range of motion (ROM), what explanations would the nurse give to the patient? (Select all that apply.) a. The exercises are the only way to prevent contractures. b. Active and passive ROM maintains function of body parts. c. ROM will reassure the patient that movement is still possible. d. Movement promotes mobilization of interstitial fluid back into the vascular bed. e. Active and passive ROM can only be done while the dressings are being changed.

ANS: b, c, d 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.

Which wound description indicates a need for excision and grafting? (select all that apply) a. Red, painful blisters b. Leathery, brown, exposed tendon c. Pearly white color, insensitive to pain, dry d. Charred eschar, visible thrombosed blood vessels e. Large, fluid-filled vesicles, moderate edema, moist, red

ANS: b, c, d Full-thickness burns require skin grafts to heal since the epidermis and dermis are destroyed. The burns are generally dry and leathery. Receptors in the dermis are destroyed so the patient will not report pain. Full-thickness burns appear pearly white, red, brown, black, or charred. Partial-thickness burns are moist, red, and painful. Thin-walled blisters or bulla are characteristic of partial-thickness burns. Skin grafting is not needed since the burns will heal over time.

Fluid and electrolyte shifts that occur during the early emergent phase of a burn injury include a. adherence of albumin to vascular walls. b. movement of potassium into the vascular space. c. movement of sodium and water into the interstitial space. d. hemolysis of red blood cells from large volumes of rapidly administered fluid.

ANS: c During the emergency phase, sodium and water rapidly shift to the interstitial spaces and stay there until edema formation ceases.

When caring for a patient with an electrical burn injury, which health care provider prescription would the nurse question? a. Mannitol 75 gram IV b. Urine for myoglobulin c. Lactated Ringer's solution at 25 mL/hr d. Sodium bicarbonate 24 mEq every 4 hours

ANS: c 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 nurse caring for a patient with second- and third-degree burns to 50% of the body is preparing fluid resuscitation based on the Parkland (Baxter) formula. The nurse would plan to administer a. the total 24-hour fluid requirement in the first 8 hours. b. one half of the total 24-hour fluid requirement in the first 4 hours. c. one half of the total 24-hour fluid requirement in the first 8 hours. d. one third of the total 24-hour fluid requirement in the first 4 hours.

ANS: c 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.

Which patient would the nurse prepare to transfer to a regional burn center? a. A 25-yr-old pregnant patient with a carboxyhemoglobin level of 1.5% b. A 39-yr-old patient with a partial-thickness burn to the right upper arm c. A 53-yr-old patient with a chemical burn to the anterior chest and neck d. A 42-yr-old patient who is scheduled for skin grafting of a burn wound

ANS: c 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. Page 496 Table 26.3 Burn Center Referral Criteria Burn injuries that should be referred to a burn center include the following: • Partial-thickness burns greater than 10% total body surface area (TBSA) • Burns that involve the face, hands, feet, genitalia, perineum, or major joints • Third-degree burns in any age-group • Electrical burns, including lightning injury • Chemical burns • Inhalation injury • Injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality • Any patient with burns and concomitant trauma (e.g., fractures) in which the burn injury poses the greatest risk for morbidity or mortality. In such cases, if the trauma poses a greater immediate risk, the patient may be stabilized in a trauma center before being transferred to a burn unit. HCP judgment is necessary in such situations and would be in concert with the regional medical control plan and triage protocols. • Burned children in hospitals without qualified personnel or equipment for the care of children • Burn injury in patients who will need special social, emotional, or rehabilitative intervention

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 the patient? a. Replace the blood lost. b. Maintain a neutral pH. c. Maintain fluid balance. d. Replace serum potassium.

ANS: c The 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.

A patient has 25% TBSA burn from a car fire. His wounds have been debrided and covered with a silver-impregnated dressing. What is the most important nursing intervention following surgery? a. Wash the wound with soap and water 3 times a day. b. Medicate for pain relief in between dressing changes. c. Reapply a new dressing without disturbing the wound bed. d. Assess the wound for signs of infection during dressing changes.

ANS: d Infection is the most serious threat concerning further tissue injury and possible sepsis.

A patient is recovering from second- and third-degree burns over 30% of his body, and the burn care team is planning for discharge. The first action the nurse would take when meeting with the patient would be to a. arrange a return-to-clinic appointment and prescription for pain medications. b. give the patient written information and websites resources for burn survivors. c. teach the patient and the caregiver proper wound care to be performed at home. d. review the patient's current health care status and readiness for discharge to home.

ANS: d The patient with a major burn injury will experience a long and exhausting recovery both physically and emotionally. Patients are often very fearful about how they will manage at home. The patient would benefit first from the nurse's review of the overall health and readiness for discharge. Afterward, the nurse should discuss recovery plans and follow-up after discharge.

In caring for a patient with burns to the back, the nurse determines the patient is moving out of the emergent phase of burn injury when what is observed? a. Serum sodium and potassium increase. b. Serum sodium and potassium decrease. c. Edema and arterial blood gases improve. d. Diuresis occurs and hematocrit decreases.

ANS: d 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.

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 would the nurse expect? a. Severe pain, blisters, and blanching with pressure b. Pain, minimal edema, and blanching with pressure c. Redness, evidence of inhalation injury, and charred skin d. No pain, waxy white skin, and no blanching with pressure

ANS: d 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.