Burns

An 80-kg patient with burns over 30% of total body surface area (TBSA) is admitted to the burn unit. Using the Parkland formula of 4 mL/kg/%TBSA, what is the IV infusion rate (mL/hour) for lactated Ringer's solution that the nurse will administer during the first 8 hours?

600 mL

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?

Use pulse oximetry to check the oxygen saturation.

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?

Hydromorphone (Dilaudid)

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 action will the nurse anticipate taking now?

Increase the rate of the ordered IV solution.

In which order will the nurse take these actions when doing a dressing change for a partial-thickness burn wound on a patient's chest? (Put a comma and a space between each answer choice [A, B, C, D, E].)

1. Administer IV fentanyl (Sublimaze). 2. Clean wound with saline-soaked gauze. 3. Apply silver sulfadiazine cream. 4. Apply sterile gauze dressing. 5. Document wound appearance.

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?

938 mL/hour

Which patient should the nurse assess first?

A patient with smoke inhalation who has wheezes and altered mental status

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?

Continue to monitor the urine output.

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?

Extremity movement

A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take?

Notify the health care provider and prepare for endotracheal intubation.

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?

Notify the health care provider.

A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first?

Place on cardiac monitor.

A patient who was found unconscious in a burning house is brought to the emergency department by ambulance. The nurse notes that the patient's skin color is bright red. Which action should the nurse take first?

Place the patient on 100% oxygen using a non-rebreather mask.

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?

Remove nonadherent clothing and watch.

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 an intervention by the charge nurse?

The new nurse uses clean latex gloves when applying antibacterial cream to a burn wound.

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?

27%

During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion?

Measure hourly urine output.

A young adult patient who is in the rehabilitation phase after having deep partial-thickness face and neck burns has a nursing diagnosis of disturbed body image. Which statement by the patient indicates that the problem is resolving?

"Do you think dark beige makeup foundation would cover this scar on my cheek?"

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?

Serum potassium 6.1 mEq/L

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?

Stools for occult blood

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 by the nurse is best?

"It's true that your life may be different. What concerns you the most?"

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 34-year-old patient who has a weight loss of 15% from admission and requires enteral feedings.

Which nursing action is a priority for a patient who has suffered a burn injury while working on an electrical power line?

Stabilize the cervical spine.

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?

Apply water-based cream to burned areas frequently.

A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first?

Auscultate the patient's lung sounds.

When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the skin is dry, pale, hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth?

Full-thickness skin destruction

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?

Elevate the right arm and hand on pillows and extend the fingers.

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?

Insert a feeding tube and initiate enteral feedings.

Eight hours after a thermal burn covering 50% of a patient's total body surface area (TBSA) the nurse assesses the patient. Which information would be a priority to communicate to the health care provider?

Urine output is 20 mL per hour for the past 2 hours.

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?

Vanilla milkshake

While the patient's full-thickness burn wounds to the face are exposed, what is the best nursing action to prevent cross contamination?

Wear gowns, caps, masks, and gloves during all care of the patient.