Burns

The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide most reliable indicator for determining the adequacy? A) vital signs B) UOP C) Mental status D) Peripheral pulses

B) UOP

A nurse on a burn unit is caring for a patient in the acute phase of burn care. While performing an assessment during this phase of burn care, the nurse recognizes that airway obstruction related to upper airway edema may occur up to how long after the burn injury? A)2 days B)3 days C)5 days D)1 week

A)2 days

A home care nurse is performing a visit to a patients home to perform wound care following the patients hospital treatment for severe burns. While interacting with the patient, the nurse should assess for evidence of what complication? A)Psychosis B)Post-traumatic stress disorder C)Delirium D)Vascular dementia

B)Post-traumatic stress disorder

An adult client was burned in an explosion. The burn initially affected the client's entire face. and the upper of of the anterior torso, and there were circumferential burns to the lower half of both arms. The clients clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would bet the extent of the burn injury? A) 18% B) 24% C) 36% D) 48%

C) 36%

A nurse is teaching a patient with a partial-thickness wound how to wear his elastic pressure garment. How would the nurse instruct the patient to wear this garment? A)4 to 6 hours a day for 6 months B)During waking hours for 2 to 3 months after the injury C)Continuously D)At night while sleeping for a year after the injury

C)Continuously

A nurse is developing a care plan for a patient with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. What is the best rationale for this intervention? A)To prevent neuropathies B)To prevent wound breakdown C)To prevent contractures D)To prevent heterotopic ossification

C)To prevent contractures

The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy? A) Return of distal pulses B) Brisk bleeding from the site C) Decreasing edema formation D) Formation of granulation tissue

A) Return of distal pulses

A public health nurse has reviewed local data about the incidence and prevalence of burn injuries in the community. These data are likely to support what health promotion effort? A)Education about home safety B)Education about safe storage of chemicals C)Education about workplace health threats D)Education about safe driving

A)Education about home safety

A patient is admitted to the burn unit after being transported from a facility 1000 miles away. The patient has burns to the groin area and circumferential burns to both upper thighs. When assessing the patients legs distal to the wound site, the nurse should be cognizant of the risk of what complication? A)Ischemia B)Referred pain C)Cellulitis D)Venous thromboembolism (VTE)

A)Ischemia

An emergency department nurse learns from the paramedics that they are transporting a patient who has suffered injury from a scald from a hot kettle. What variables will the nurse consider when determining the depth of burn? A)The causative agent B)The patients preinjury health status C)The patients prognosis for recovery D)The circumstances of the accident

A)The causative agent

The current phase of a patients treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the patient is in what phase of burn care? A)Emergent B)Immediate resuscitative C)Acute D)Rehabilitation

C)Acute

A nurse who is taking care of a patient with burns is asked by a family member why the patient is losing so much weight. The patient is currently in the intermediate phase of recovery. What would be the nurses most appropriate response to the family member? A)He's on a calorie-restricted diet in order to divert energy to wound healing. B)His body has consumed his fat deposits for fuel because his calorie intake is lower than normal. C)He actually hasnt lost weight. Instead, theres been a change in the distribution of his body fat. D)He lost many fluids while he was being treated in the emergency phase of burn care.

B)His body has consumed his fat deposits for fuel because his calorie intake is lower than normal.

A patients burns have required a homograft. During the nurses most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurses most appropriate response? A)Perform mechanical dbridement to remove the exudate and prevent further infection. B)Inform the primary care provider promptly because the graft may need to be removed. C)Perform range of motion exercises to increase perfusion to the graft site and facilitate healing. D)Document this finding as an expected phase of graft healing.

B)Inform the primary care provider promptly because the graft may need to be removed.

A patient has experienced an electrical burn and has developed thick eschar over the burn site. Which of the following topical antibacterial agents will the nurse expect the physician to order for the wound? A)Silver sulfadiazine 1% (Silvadene) water-soluble cream B)Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream C)Silver nitrate 0.5% aqueous solution D)Acticoat

B)Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream

A patient who was burned in a workplace accident has completed the acute phase of treatment and the plan of care has been altered to prioritize rehabilitation. What nursing action should be prioritized during this phase of treatment? A)Monitoring fluid and electrolyte imbalances B)Providing education to the patient and family C)Treating infection D)Promoting thermoregulation

B)Providing education to the patient and family

The nurse is preparing the patient for mechanical dbridement and informs the patient that this will involve which of the following procedures? A)A spontaneous separation of dead tissue from the viable tissue B)Removal of eschar until the point of pain and bleeding occurs C)Shaving of burned skin layers until bleeding, viable tissue is revealed D)Early closure of the wound

B)Removal of eschar until the point of pain and bleeding occurs

A patient has sustained a severe burn injury and is thought to have an impaired intestinal mucosal barrier. Since this patient is considered at an increased risk for infection, what intervention will best assist in avoiding increased intestinal permeability and prevent early endotoxin translocation? A)Early enteral feeding B)Administration of prophylactic antibiotics C)Bowel cleansing procedures D)Administration of stool softeners

A)Early enteral feeding

A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurses immediate, priority concern when planning this patients care? A)Fluid status B)Risk of infection C)Nutritional status D)Psychosocial coping

A)Fluid status

A patient in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the patients laboratory studies, the nurse will expect the results to indicate what? A)Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis B)Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis C)Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis D)Hypokalemia, hyponatremia, elevated hematocrit, and metabolic alkalosis

A)Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis

A patient is in the acute phase of a burn injury. One of the nursing diagnoses in the plan of care is Ineffective Coping Related to Trauma of Burn Injury. What interventions appropriately address this diagnosis? Select all that apply. A)Promote truthful communication. B)Avoid asking the patient to make decisions. C)Teach the patient coping strategies. D)Administer benzodiazepines as ordered. E)Provide positive reinforcement.

A)Promote truthful communication. C)Teach the patient coping strategies. E)Provide positive reinforcement.

A nurse is caring for a patient in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values? A)Sodium deficit B)Decreased prothrombin time (PT) C)Potassium deficit D)Decreased hematocrit

A)Sodium deficit

A burn patient is transitioning from the acute phase of the injury to the rehabilitation phase. The patient tells the nurse, I cant wait to have surgery to reconstruct my face so I look normal again. What would be the nurses best response? A)Thats something that you and your doctor will likely talk about after your scars mature. B)That is something for you to talk to your doctor about because its not a nursing responsibility. C)I know this is really important to you, but you have to realize that no one can make you look like you used to. D)Unfortunately, its likely that you will have most of these scars for the rest of your life.

A)Thats something that you and your doctor will likely talk about after your scars mature.

The nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which unsafe component of protective isolation technique? A) Using sterile sheets and linens B) Performing strict hand-washing technique C) Wearing gloves and gown only when providing direct care for the client D) Wearing protective garb, including mask, gloves, cap, shoe covers, gowns, and plastic apron

C) Wearing gloves and gown only when providing direct care for the client

A nurse who provides care on a burn unit is preparing to apply a patients ordered topical antibiotic ointment. What action should the nurse perform when administering this medication? A)Apply the new ointment without disturbing the existing layer of ointment. B)Apply the ointment using a sterile tongue depressor. C)Apply a layer of ointment approximately 1/16 inch thick. D)Gently irrigate the wound bed after applying the antibiotic ointment.

C)Apply a layer of ointment approximately 1/16 inch thick.

A patient has experienced burns to his upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action? A)Instruct the patient to keep the wound site in a dependent position. B)Administer PRN analgesia as ordered. C)Assess the patients peripheral pulses distal to the dressing. D)Assist with passive range of motion exercises to set the new dressing.

C)Assess the patients peripheral pulses distal to the dressing.

A triage nurse in the emergency department (ED) receives a phone call from a frantic father who saw his 4-year-old child tip a pot of boiling water onto her chest. The father has called an ambulance. What would the nurse in the ED receiving the call instruct the father to do? A)Cover the burn with ice and secure with a towel. B)Apply butter to the area that is burned. C)Immerse the child in a cool bath. D)Avoid touching the burned area under any circumstances.

C)Immerse the child in a cool bath.

A patient experienced a 33% TBSA burn 72 hours ago. The nurse observes that the patients hourly urine output has been steadily increasing over the past 24 hours. How should the nurse best respond to this finding? A)Obtain an order to reduce the rate of the patients IV fluid infusion. B)Report the patients early signs of acute kidney injury (AKI). C)Recognize that the patient is experiencing an expected onset of diuresis. D)Administer sodium chloride as ordered to compensate for this fluid loss.

C)Recognize that the patient is experiencing an expected onset of diuresis.

A patient with a partial-thickness burn injury had Biobrane applied 2 weeks ago. The nurse notices that the Biobrane is separating from the burn wound. What is the nurses most appropriate intervention? A)Reinforce the Biobrane dressing with another piece of Biobrane. B)Remove the Biobrane dressing and apply a new dressing. C)Trim away the separated Biobrane. D)Notify the physician for further emergency-related orders.

C)Trim away the separated Biobrane.

A nurse is caring for a patient who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis? A)Activity Intolerance B)Anxiety C)Ineffective Coping D)Acute Pain

D)Acute Pain

A patient is brought to the ED by paramedics, who report that the patient has partial-thickness burns on the chest and legs. The patient has also suffered smoke inhalation. What is the priority in the care of a patient who has been burned and suffered smoke inhalation? A)Pain B)Fluid balance C)Anxiety and fear D)Airway management

D)Airway management

A nurse is performing a home visit to a patient who is recovering following a long course of inpatient treatment for burn injuries. When performing this home visit, the nurse should do which of the following? A)Assess the patient for signs of electrolyte imbalances. B)Administer fluids as ordered. C)Assess the risk for injury recurrence. D)Assess the patients psychosocial state.

D)Assess the patients psychosocial state.

The nurse caring for a patient who is recovering from full-thickness burns is aware of the patients risk for contracture and hypertrophic scarring. How can the nurse best mitigate this risk? A)Apply skin emollients as ordered after granulation has occurred. B)Keep injured areas immobilized whenever possible to promote healing. C)Administer oral or IV corticosteroids as ordered. D)Encourage physical activity and range of motion exercises.

D)Encourage physical activity and range of motion exercises.

A patient is brought to the emergency department from the site of a chemical fire, where he suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the patients arm? A)Superficial partial-thickness B)Deep partial-thickness C)Full partial-thickness D)Full-thickness

D)Full-thickness

A nurse is caring for a patient with burns who is in the later stages of the acute phase of recovery. The plan of nursing care should include which of the following nursing actions? A)Maintenance of bed rest to aid healing B)Choosing appropriate splints and functional devices C)Administration of beta adrenergic blockers D)Prevention of venous thromboembolism

D)Prevention of venous thromboembolism

While performing a patients ordered wound care for the treatment of a burn, the patient has made a series of sarcastic remarks to the nurse and criticized her technique. How should the nurse best interpret this patients behavior? A)The patient may be experiencing an adverse drug reaction that is affecting his cognition and behavior. B)The patient may be experiencing neurologic or psychiatric complications of his injuries. C)The patient may be experiencing inconsistencies in the care that he is being provided. D)The patient may be experiencing anger about his circumstances that he is deflecting toward the nurse.

D)The patient may be experiencing anger about his circumstances that he is deflecting toward the nurse.

An emergency department nurse has just admitted a patient with a burn. What characteristic of the burn will primarily determine whether the patient experiences a systemic response to this injury? A)The length of time since the burn B)The location of burned skin surfaces C)The source of the burn D)The total body surface area (TBSA) affected by the burn

D)The total body surface area (TBSA) affected by the burn

An occupational health nurse is called to the floor of a factory where a worker has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to cool the burn. How should the nurse cool the burn? A)Apply ice to the site of the burn for 5 to 10 minutes. B)Wrap the patients affected extremity in ice until help arrives. C)Apply an oil-based substance or butter to the burned area until help arrives. D)Wrap cool towels around the affected extremity intermittently.

D)Wrap cool towels around the affected extremity intermittently.

A patient arrives in the emergency department after being burned in a house fire. The patients burns cover the face and the left forearm. What extent of burns does the patient most likely have? A)13% B)25% C)9% D)18%

D)18%

A nurse has reported for a shift at a busy burns and plastics unit in a large university hospital. Which patient is most likely to have life-threatening complications? A)A 4-year-old scald victim burned over 24% of the body B)A 27-year-old male burned over 36% of his body in a car accident C)A 39-year-old female patient burned over 18% of her body D)A 60-year-old male burned over 16% of his body in a brush fire

A)A 4-year-old scald victim burned over 24% of the body

A patient who is in the acute phase of recovery from a burn injury has yet to experience adequate pain control. What pain management strategy is most likely to meet this patients needs? A)A patient-controlled analgesia (PCA) system B)Oral opioids supplemented by NSAIDs C)Distraction and relaxation techniques supplemented by NSAIDs D)A combination of benzodiazepines and topical anesthetics

A)A patient-controlled analgesia (PCA) system

The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Base on this level, the nurse would anticipate noting which sign in the client? A) Coma B) Flushing C) Dizziness D) Tachycardia

B) Flushing

A client was brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to get out of a car fire. The nurse should implement which nursing actions for this client? A) Restrict fluids B) Assess for airway patency C) Administer oxygen as prescribed D) Place a cooling blanket on the client E) Elevate extremities if no fractures are present F) Prepare to give oral pain medication as prescribed

B) Assess for airway patency C) Administer oxygen as prescribed E) Elevate extremities if no fractures are present

The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client? A) Out-of-bed activities B) Bathroom privileges C) Immobilization of the affected leg D) Placing the left leg in a dependent position

C) Immobilization of the affected leg

A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50mm/Hg, a pulse rate of 110/beats per minute, and a urine output of 20ml over the past hour. The nurse reports the findings to the health care provider and anticipates which prescription? A) Transfusing 1 unit of packed RBCs B) Administering a diuretic to increase urine output C) Increasing the amount of IV fluid D) Changing the IV LR to 5% dextrose

C) Increasing the amount of IV fluid

A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for this client? A) 100% O2 via an arousal mask B) Oxygen via nasal cannula 6L/minute C) Oxygen via nasal cannula at 15L/minute D) 100% Oxygen via a tight-fitting NRB face mask

D) 100% Oxygen via a tight-fitting NRB face mask