Exam 3 EAQs: Ch. 24 - Burn Management

The nurse is providing education to a patient who is in the rehabilitation phase of burn recovery after burning the arm with scalding water. Which of these statements by the patient indicates a need for further instruction? "If the area itches, I can apply a water-based moisturizer." "After a month, I will be able to go to the beach to get a tan." "I will need to wear the pressure garment for 24 hours a day." "I will continue the range-of-motion exercises on a regular schedule."

"After a month, I will be able to go to the beach to get a tan." Burn patients must protect healed burn areas from direct sunlight for about three months to prevent hyperpigmentation and sunburn injury. They should always wear sunscreen when they are outside. Water-based moisturizers are appropriate for itching. Pressure garments and masks should never be worn over unhealed wounds and, once a wearing schedule has been established, are removed only for short periods while bathing. Pressure garments are worn up to 24 hours a day for as long as 12 to 18 months. The range-of-motion exercises are important to prevent contractures that may develop as new tissue shortens.

A patient is recovering from second- and third-degree burns over 30% of the body and is now ready for discharge. Just before leaving, the patient states, "What's going to happen to me? Will I ever look normal again?" The nurse recognizes that this patient is exhibiting which emotional response to the patient's type of injury? Fear Guilt Anxiety Depression

Anxiety Recovery from a 30% total body surface area (TBSA) burn injury takes time and is exhausting, both physically and emotionally for the patient. The health care team may think that a patient is ready for discharge, but the patient may not have any idea that discharge is being contemplated in the near future. Patients are often very fearful about how they will manage at home. While fear, anger, guilt, and depression are all common emotions experienced by a burn patient, this patient's statements reflect feelings of anxiety.

A patient has thermal burns on the face, including the cheeks and the area around the eyes. Which action would the nurse take? Turn eyelashes inward towards the eyeball. Wrap sterile gauze around the face. Cover the face with ointment and gauze. Apply ointment only without the use of gauze.

Cover the face with ointment and gauze. The face is highly vascular and may become edematous after a thermal burn. It should be covered with ointment and gauze to prevent vascularization and swelling. The nurse should ensure that eyelashes are not turned inward. Wrapping gauze around the face will create pressure on delicate facial structures. The gauze is required to cover the face after the application of ointment to prevent infection.

Which intervention would the nurse provide when caring for a patient with a burn injury who is in the in the acute phase? Encourage and assist patient with self-care as possible Discuss possible need for home care nursing Discuss possible reconstructive surgery Begin intravenous (IV) fluid replacement

Encourage and assist patient with self-care as possible Encouraging and assisting the patient with self-care as much as they are able begins in the acute phase. Discussing the need for both home care following discharge and the need for reconstructive surgery occur during the rehabilitation phase. Beginning fluid replacement occurs in the emergent phase.

A patient with burns needs permanent skin grafting. Which grafts should the nurse consider? Select all that apply. Integra AlloDerm Autograft Homograft Heterograft

Integra AlloDerm Autograft Integra is obtained from bovine collagen and glycosaminoglycan bonded to silicone and gives permanent coverage. AlloDerm is obtained from a cellular dermal matrix derived from donated human skin and can be used for permanent grafting. Autograft is from patient's own skin and can be used for permanent grafting. Homograft is obtained from cadaveric skin and can be used as temporary graft from 3 days to 2 weeks. Heterograft is obtained from porcine skin and can be used as temporary graft from three days to two weeks.

A nurse is caring for a patient with second- and third-degree burns to 50% of the body. The nurse prepares fluid resuscitation based on knowledge of the Parkland (Baxter) formula that includes which recommendation? The total 24-hour fluid requirement should be administered in the first 8 hours. One-half of the total 24-hour fluid requirement should be administered in the first 8 hours. One-third of the total 24-hour fluid requirement should be administered in the first 4 hours. One-half of the total 24-hour fluid requirement should be administered in the first 4 hours.

One-half of the total 24-hour fluid requirement should be administered in the first 8 hours. Fluid resuscitation with the Parkland (Baxter) formula recommends that one half of the total fluid requirement should be administered in the first eight hours, one quarter of total fluid requirement should be administered in the second eight hours, and one quarter of total fluid requirement should be administered in the third eight hours.

While planning physical therapy for a patient suffering from burns, which should be included? Select all that apply. Perform exercises before wound cleansing. Practice physical therapy only occasionally. Perform passive and active ROM on all joints. Provide pillows to sleep for patients with neck burns. Perform exercises during and after wound cleansing.

Perform passive and active ROM on all joints. Perform exercises during and after wound cleansing. Perform passive and active ROM on all joints to avoid contractures and prevent compromising the patient's cardiopulmonary status. It is not a good habit to practice physical therapy only occasionally. This is because continuous physical therapy throughout burn recovery is imperative if the patient needs to regain and maintain muscle strength and optimal joint function. A good time for exercise is during and after wound cleansing, when the skin is softer and bulky dressings are removed. Performing exercises before wound cleansing is not appropriate. Patients with neck burns should continue to sleep without pillows or with the head hanging slightly over the top of the mattress to encourage hyperextension and avoid contractures.

A patient who sustained burn injuries is receiving daily treatments. The patient tells the caregiver, "The nurses enjoy hurting me." What should the nurse suspect? Choose the best answer. This patient must be having hallucinations. This patient might be having schizophrenia. This patient has a serious psychiatric condition. This is a normal reaction to an extraordinary life event.

This is a normal reaction to an extraordinary life event. Patients who have sustained burn injuries may experience a variety of emotions, including fear, anxiety, anger, guilt, and depression. The given example shows that the patient is angry and depressed, and it is important to reassure the patient and caregivers that these reactions may be normal and can be expected. The nurse should not assume from this reaction that the patient is experiencing hallucinations or any serious psychiatric conditions, including schizophrenia.

While teaching care guidelines to a family member of a patient with burns, the nurse instructs the family member to include foods rich in omega-3 fatty acids in the patient's diet. What is the rationale behind the nurse's instruction? To improve sleep To prevent blood clots To promote weight gain To decrease stomach acid

To prevent blood clots A patient with severe burns is at greater risk of venous thromboembolism. Omega-3 fatty acids are natural anticoagulants that decrease platelet aggregation. Eating foods rich in tryptophan, not omega-3 fatty acids, improves the patient's sleeping pattern. Tryptophan is an amino acid that blocks body wakeup cycles and promotes sleep. Foods rich in protein and fats, like peanut butter and red meat, help the patient gain weight. Avoiding spicy foods and drinking plenty of pure water helps decrease stomach acid.

The nurse is teaching strategies to reduce burn injuries to a group of new parents. Which comment, by a parent, indicates a need for further teaching? "We will have fire exit drills once a month at home." "I will not use gasoline in the fireplace when starting a fire." "I will make sure the hot water temperature is set at 140° F (60° C)." "We will install hard-wired smoke detectors on each level of our home."

"I will make sure the hot water temperature is set at 140° F (60° C)." Hot water heaters set at 140° F (60° C) or higher are a burn hazard in the home; the temperature should be set at less than 120° F (40° C). A risk-reduction strategy for household fires is to encourage regular home fire exit drills. Gasoline or other flammable liquids should never be used to start a fire. 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.

As per the Parkland (Baxter) formula, the estimated total fluid requirement in the first 24 hours for a severely burned patient who weighs 80 kg and when more than 40% of the total body surface area (TBSA) is burned should be ___ mL

12800 mL According to the Parkland (Baxter) formula: 4 mL of lactated Ringer's solution should be administered per kilogram (kg) of body weight per percent of total body surface area (%TBSA) burned in the first 24 hours after the burn. For an 80-kg patient with a 40% TBSA burn, 4 mL × 80 kg × 40 TBSA burned = 12,800 mL in 24 hours.

Fluid resuscitation is an important intervention in burn patients. The nurse recognizes that what fluid is recommended for the first 24 hours after a burn? 1 to 2 mL lactated Ringer's/kg/%TBSA burned 2 to 4 mL lactated Ringer's/kg/%TBSA burned 6 to 8 mL lactated Ringer's/kg/%TBSA burned 8 to 10 mL lactated Ringer's/kg/%TBSA burned

2 to 4 mL lactated Ringer's/kg/%TBSA burned Fluid resuscitation is an important intervention in burn management. It helps to replenish the fluid loss caused by burns and maintain the fluid and electrolyte balance. The fluid recommendation for the first 24 hours is 2 to 4 mL lactated Ringer's/kg/%TBSA burned. A fluid volume of 1 to 2 mL lactated Ringer's/kg/%TBSA burned would be inadequate to meet the patient's requirement. Volumes of 6 to 8 mL lactated Ringer's/kg/%TBSA burned and 8 to 10 mL lactated Ringer's/kg/%TBSA burned may cause fluid overload.

A nurse works in an emergency department. Which patients are appropriate for the nurse to refer to the burn care unit? Select all that apply. A patient with burns of the feet A patient with an inhalation injury An elderly patient with third-degree burns A patient with burns involving minor joints A patient with partial thickness burns involving 8% of total body surface area

A patient with burns of the feet A patient with an inhalation injury An elderly patient with third-degree burns A burn care unit provides advanced care to burn patients to prevent complications and keep the condition from worsening. Inhalation injury increases the risk of airway obstruction and requires a referral to the burn unit. Burns of both feet is associated with complications like contractures, and needs to be referred to the burn care unit. Third-degree burns in any age-group require referral. Burns involving minor joints do not require referral to burn centers; however, burns of major joints require referral. Partial thickness burns require referral if they involve more than 10% of the body surface area.

A nurse is attending to a patient with partial-thickness burns on the hands and legs. What actions should the nurse perform as a part of the wound care for the emergent phase of treatment? Select all that apply. Avoid using topical antibiotics. Administer a tetanus antitoxin. Perform debridement as required. Avoid using antimicrobial dressings. Assess the extent and depth of the burns.

Administer a tetanus antitoxin. Perform debridement as required. Assess the extent and depth of the burns. The burn management involves emergent phase, acute phase, and rehabilitation phase. The emergent phase involves early management of the burns patient and includes airway management, and fluid and wound therapy. Tetanus antitoxin should be administered to prevent sepsis. Assessment of extent and depth of burns should be done to determine the severity of burns, plan burns management, and consider referring to a burn center. Debridement should be performed as required to keep the wound clean, remove any chemical causing the burn, or to prevent further tissue damage. Use of topical antibiotics and antimicrobial dressings are not of prime importance in the emergent phase; they are usually used in the acute and rehabilitation phases.

A burn patient has not received any active tetanus immunization within the previous 12 years. What is the primary nursing measure to help prevent the development of tetanus in the patient? Administer tetanus toxoid Provide musculoskeletal relaxants Provide 100% oxygen to the patient Administer tetanus immunoglobulin

Administer tetanus immunoglobulin Because the patient has not received any active immunization in the past 12 years, tetanus immunoglobulin administration is the primary measure. It would help in preventing development of tetanus. Tetanus toxoid administration would have been the primary measure if the patient had received active immunization within the past 10 years. Providing 100% oxygen does not ensure aerobic conditions at the burn area. Musculoskeletal relaxants will be helpful only after the patient develops tetanus.

A patient sustains burns covering 35% of the body surface area. The patient weighs 100 kg. Which action is most appropriate for the nurse to take during the early course of the patient's care? Administering 3500 mL of colloid IV fluids over the 8 hours after injury Administering 140 mL/hr of colloid IV fluids for the 24 hours after injury Administering 7000 mL of crystalloid IV fluids over the 8 hours after injury Administering 14,000 mL of crystalloid IV fluids over the 12 hours after injury

Administering 7000 mL of crystalloid IV fluids over the 8 hours after injury Crystalloid solutions, such as Ringer's lactate, are indicated for use in the initial IV fluid therapy for a burn patient. IV fluids for the first 24 hours may be calculated with the use of the Parkland formula based on body surface area (BSA), 4 mL/kg × BSA; therefore (4 mL × 100 kg) × 35 = 14,000 mL. The Parkland formula calls for half of the total fluids to be given over the first 8 hours, with the remaining given over the next 16 hours. Therefore the IV fluid prescription would be 7000 mL over 8 hours and 7000 mL over the next 16 hours. Administering 3500 mL of colloid IV fluids over the first 8 hours or 140 mL/hr of colloid IV fluids for 24 hours is incorrect because the volumes are incorrect and colloid fluids are not used during the fluid resuscitation period for burns (first 24 hours).

A nurse is attending to a patient with extensive burns. What prophylactic treatment should the nurse plan to prevent a Curling's ulcer in this patient? Select all that apply. Antacids Antidiarrheal H 2-histamine blockers Proton pump inhibitors Calcium channel blockers

Antacids H 2-histamine blockers Proton pump inhibitors Antacids are used prophylactically to neutralize the acids present in the stomach. H 2-histamine blockers (e.g., ranitidine) are used to inhibit histamine, which causes an increase in acid levels. Proton pump inhibitors (e.g., esomeprazole) help to inhibit the secretion of hydrochloric acid, which increases as a stress response to the decreased blood flow to the gastrointestinal tract after burns. Antidiarrheals are useful in providing symptomatic relief for diarrhea. They cannot prevent a Curling's ulcer. Calcium channel blockers have no effect on protecting the gastrointestinal tract or on preventing development of Curling's ulcers.

A patient is admitted to the burn center with burns of the face, upper chest, and hands after fireworks exploded in the patient's garage, catching the patient's shirt on fire. On assessment, the nurse notes that the patient is coughing up black sputum, has singed nasal hair, darkened oral and nasal membranes, and smoky breath with increasing shortness of breath and hoarseness. Which of these actions would be the most appropriate for the nurse to take next? Insert a Foley catheter and monitor output. Obtain vital signs and a stat arterial blood gas (ABG). Obtain a sputum specimen and send it to the lab stat. Anticipate the need for endotracheal intubation and notify the health care provider.

Anticipate the need for endotracheal intubation and notify the health care provider. Inhalation injury results from exposure of the respiratory tract to intense heat or flames with inhalation of noxious chemicals, smoke, or carbon monoxide. The nurse should anticipate the need for endotracheal intubation and mechanical ventilation, because this patient is demonstrating signs of severe respiratory distress. The nurse should also obtain vital signs and ABGs and insert a Foley, but these interventions are not a priority at this time. A sputum sample is not necessary at this time.

A patient has 20% total body surface area (TBSA) burns from a brush fire. For the past week, the patient's wounds have been debrided and covered with a silver-impregnated dressing. Today the nurse noticed that the partial-thickness burn wounds have been fully debrided. What would be the nurse's priority intervention for wound care at this time? Reapply a new dressing without disturbing the wound bed. Apply fine-meshed petroleum gauze to the debrided areas. Wash the wound aggressively with sterile saline three times a day. Apply cool compresses for pain relief in between dressing changes.

Apply fine-meshed petroleum gauze to the debrided areas. When the partial-thickness burn wounds have been fully debrided, a protective, coarse or fine-meshed, greasy-based (paraffin or petroleum) gauze dressing is applied to protect the re-epithelializing keratinocytes as they resurface and close the open wound bed. The nurse would not wash the wound aggressively with saline three times daily, apply cool compresses, or apply a new dressing at this time.

When attending to a patient with severe burns, what precautions should the nurse take to maintain adequate nutrition? Select all that apply. Assess respiratory rate every two hours. Assess bowel sounds every eight hours. Begin large amounts of feeding within first six hours. Begin early enteral feeding with smaller-bore tubes. Begin the feedings slowly at a rate of 20 to 40 mL/hr.

Assess bowel sounds every eight hours. Begin early enteral feeding with smaller-bore tubes. Begin the feedings slowly at a rate of 20 to 40 mL/hr. The nurse should assess bowel sounds every eight hours to ensure proper functioning of the bowels before starting oral nutrition. The nurse should also begin early enteral feeding with smaller-bore tubes, because this preserves gastrointestinal (GI) function, increases intestinal blood flow, and promotes optimal conditions for wound healing. The feedings should begin slowly at a rate of 20 to 40 mL/hr to protect the GI function and gradually increase as the patient improves. Assessing the respiratory rate every two hours is not related to nutritional therapy. Large amounts of feeding within the first six hours may overload the system and affect the GI function.

A patient is brought to the emergency department (ED) with partial-thickness burns on the hands and chest caused by a fire at the patient's house. What actions should the nurse perform to provide appropriate burn management for this patient? Select all that apply. Assess for inhalation injury. Provide 100% humidified oxygen. Avoid dry dressings on the wounds. Assess airway, breathing, and circulation. Avoid mechanical ventilation for 24 hours.

Assess for inhalation injury. Provide 100% humidified oxygen. Assess airway, breathing, and circulation. The patient should be assessed for inhalation injury. Because these burns are caused by a fire, there is a high likelihood that the patient might have inhaled fumes. After assessing the airway, the nurse should provide 100% humidified oxygen to ensure adequate ventilation. The nurse should assess the patency of the airway as well as respirations and plan for the need for intubation accordingly. Dry dressings on the wounds may be applied to cover the wounds, if required. Mechanical ventilation may be required in case of significant inhalation injury.

A young patient who experienced burns on the neck and chest from a fire at the workplace two hours ago presents to the emergency department (ED). The patient is not intubated and on assessment the nurse suspects inhalation injury. What appropriate actions should the nurse perform? Select all that apply. Assist in performing a fiberoptic bronchoscopy. Reposition the patient every one to two hours. Avoid administering 100% humidified oxygen. Do not place the patient in a high-Fowler's position. Encourage deep breathing and coughing every hour.

Assist in performing a fiberoptic bronchoscopy. Reposition the patient every one to two hours. Encourage deep breathing and coughing every hour. Within 6 to 12 hours after the burn injury in which smoke inhalation is suspected, a fiberoptic bronchoscopy should be performed to assess the lower airway. Reposition the patient every one to two hours, and provide suctioning and chest physiotherapy, as prescribed, to clear the airway. Encourage deep breathing and coughing every hour to clear the air passages and provide relief to the patient. When intubation is not performed, the treatment of inhalation injury includes administration of 100% humidified O 2 as needed. Place the patient in a high-Fowler's position, unless contraindicated, as in spinal injury, and encourage deep breathing and coughing every hour.

A patient is being treated for burns on the face and ears due to a fire at home. What precautions should the nurse take to protect the ears from damage? Select all that apply. Avoid using pillows. Keep ears free from pressure. Apply a heavy gauze dressing for fast healing. Wrap ears with sterile gauze after applying ointment. Elevate patient's head by placing rolled towel under shoulders.

Avoid using pillows. Keep ears free from pressure. Elevate patient's head by placing rolled towel under shoulders. Ears should be kept free from pressure because of their poor vascularization and tendency to become infected. Avoid using pillows, because the pressure on ear cartilage may cause chondritis, and the ear may adhere to the pillowcase, causing pain and bleeding. The patient's head is elevated by placing a rolled towel under the shoulders to reduce pressure over the ears. It helps to prevent pressure necrosis. A heavy gauze dressing should not be applied, because it can put pressure on the ears and damage them. Ears are not to be wrapped with sterile gauze after applying ointment in order to avoid pressure over the ears.

A nurse is attending to a patient who has sustained full-thickness burns covering more than 20% of total body surface area (TBSA). Which initial interventions should the nurse perform as a part of emergency burn management? Select all that apply. Begin fluid replacement. Avoid supplemental oxygen. Cover burned areas with dry dressings. Lower the burned limbs below heart level. Establish IV access with two large-bore catheters.

Begin fluid replacement. Cover burned areas with dry dressings. Establish IV access with two large-bore catheters. Begin fluid replacement to compensate for fluid loss. Cover the burned areas with dry dressings to begin the healing process and thus prevent contamination. An intravenous access should be established with two large-bore catheters to enable large amounts of fluid replacements. Supplemental oxygen is required to maintain adequate perfusion. The injured limb should be kept elevated above the heart level to prevent and decrease swelling.

A patient has sustained thermal injuries amounting to approximately 30% of his or her total body surface area. What action should the nurse take first? Cover the burned body area with ice. Immerse the burned body area in cool water . Check for a patent airway, breathing, and circulation. Cover the burned area with a clean, cool, tap water-dampened towel.

Check for a patent airway, breathing, and circulation. The first step in the management of a person who has sustained thermal injuries on 10% or more of his or her body surface is to assess the airway, breathing, and circulation. If the injury is less than 10% of total body surface area, then it would be appropriate to cover the burned area with a clean, cool, damp towel, but only after the airway, breathing, and circulation have been checked. It is not appropriate to cover the patient's afflicted area with ice, because this can cause hypothermia and vasoconstriction, which would further reduce the blood flow to the injury site. Immersing the patient or the patient's afflicted area in cool water may cause extensive heat loss.

A patient with burns of more than 5% of the total body surface area is intubated, and enteral feedings are ordered to meet nutritional demands. Which nursing interventions are appropriate for the enteral feeding of this patient? Select all that apply. Check gastric residuals frequently. Assess bowel sounds every eight hours. Determine whether the nasogastric tube is in place. Begin the feedings slowly at the rate of 10 to 20 mL/hr. Increase the feeding to the goal rate within 24 to 48 hours.

Check gastric residuals frequently. Assess bowel sounds every eight hours. Determine whether the nasogastric tube is in place. Increase the feeding to the goal rate within 24 to 48 hours.

The nurse collaborates with the health care team regarding the treatment of partial-thickness second-degree burn to the chest, abdomen, and both anterior thighs sustained by a patient. Which treatment does the nurse recognize as appropriate and within the scope of nursing practice? Application of autografts and daily sterile dressing changes Twice-weekly wound cleaning and sterile dressing changes Daily wound cleaning with debridement and sterile dressing changes Daily wound cleaning with hydrotherapy and clean dressing changes

Daily wound cleaning with debridement and sterile dressing changes Daily wound cleansing with debridement and sterile dressing changes is appropriate care for a major burn wound. As a means of promoting healing and preventing infection, wound care and dressing changes are performed once or twice a day with a sterile procedure. The other answer options are not within the scope of nursing practice and may not be appropriate treatment for the burn injury sustained.

A nurse is instructing a patient about the immediate steps that need to be taken in the case of electrical burns. What precautions should the nurse instruct as necessary to perform? Select all that apply. Do not cover the burned part with ice. Do not remove any burnt cloth from the body. Do not immerse the burned part in cool water. Cool large burns for not more than 10 minutes. Apply ice to the burned part as early as possible.

Do not cover the burned part with ice. Do not immerse the burned part in cool water. Cool large burns for not more than 10 minutes. The burned body part of a person suffering from an electrical injury should not be covered with ice, because it can cause hypothermia and vasoconstriction, and can significantly reduce the blood flow to the affected area. Do not immerse the burned part in cold water, because it may cause extensive heat loss. Cooling burns for more than 10 minutes can cause hypothermia. Applying ice to the burned part can cause hypothermia. Burnt clothes can be removed gently to avoid further tissue damage; however, clothes which are adhered to the body should not be removed.

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 should the nurse expect to include in this patient's care? Select all that apply. Escharotomy Administration of diuretics Daily cleansing and debridement Application of topical antimicrobial agent Intravenous (IV) and oral pain medications

Escharotomy Daily cleansing and debridement Application of topical antimicrobial agent Intravenous (IV) and oral pain medications Pain control is essential in the care of a patient with a burn injury. Daily cleansing and debridement, as well as application of an antimicrobial ointment, are expected interventions used to minimize infection and enhance wound healing. An escharotomy (a scalpel incision through full-thickness eschar) frequently is required to restore circulation to compromised extremities. 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 presents in the emergency department (ED) with burns on the hands and face after handling hydrochloric acid at work. What actions should the nurse perform toward the patient's burn management? Select all that apply. Apply ice to the burned area. Never wash the burn with water. Flush affected area with lots of water. Remove all chemical particles on skin. Remove all clothing containing the chemical.

Flush affected area with lots of water. Remove all chemical particles on skin. Remove all clothing containing the chemical. Remove all chemical particles on skin to remove the burn-causing agent from the patient's body. Remove all clothing containing the chemical, because the burning process continues while the chemical is in contact with the skin. Flush affected area with copious amounts of water to irrigate the skin from 20 minutes to two hours after chemical exposure to clear off the chemical on or around the affected area. Applying ice to the burned area does not help to wash away the chemical. Washing the burnt area with water helps to clean off the chemical.

To determine the adequacy of fluid resuscitation in patients who have sustained burns, the nurse should assess which measurements of cardiac parameters? Select all that apply. Heart rate less than 120 beats/minute Manual systolic BP greater than 90 mm Hg Arterial line systolic BP greater than 90 mm Hg Manual mean arterial pressure greater than 65 mm Hg Arterial line mean arterial pressure greater than 65 mm Hg

Heart rate less than 120 beats/minute Arterial line systolic BP greater than 90 mm Hg Arterial line mean arterial pressure greater than 65 mm Hg The cardiac parameters which help to assess adequacy of fluid resuscitation are heart rate less than 120 beats/minute, arterial line systolic blood pressure greater than 90 mm Hg, and arterial line mean arterial pressure greater than 65 mm Hg. Manual blood pressure and manual mean arterial blood pressure are invalid in burns because of edema and vasoconstriction.

For a patient with chemical burn of 15% total body surface area (TBSA) on the legs, what kind of food should be encouraged? High fat and high carbohydrate Low protein and low carbohydrate High protein and low carbohydrate High protein and high carbohydrate

High protein and high carbohydrate The patient with chemical burn of 15% TBSA should be encouraged to eat a high-protein, high-carbohydrate diet. Foods high in protein and high in carbohydrates are important for tissue regeneration and promote wound healing. The daily estimated caloric needs should be calculated and regularly reassessed according to the patient's changing condition.

The nurse is caring for a patient with partial- and full-thickness burns to 65% of the body. When planning nutritional interventions for this patient, what dietary choices should the nurse implement? Full liquids only Whatever the patient requests High-protein and low-sodium foods High-calorie and high-protein foods

High-calorie and high-protein foods A hypermetabolic state occurs proportional to the size of the burn area. Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. Caloric needs are often in the 5000-kcal range. Failure to supply adequate calories and protein leads to malnutrition and delayed healing.

A nurse is triaging a patient who has arrived in the emergency department with burns as a result of a fire. Which patient symptoms indicate an upper airway injury? Select all that apply. Dyspnea Hoarseness Difficulty swallowing Copious secretions Carbonaceous sputum

Hoarseness Difficulty swallowing Copious secretions An inhalation injury in the upper airways involves the mouth, oropharynx, and/or larynx. It may cause hoarseness in the voice due to the effect on the larynx. There may be difficulty in swallowing due to involvement of the mouth and oropharynx. There may be copious secretion in response to the injury to the airway. The injury to the lower airway involves trachea, bronchioles, and alveoli, and may cause carbonaceous sputum and dyspnea.

A nurse is teaching a patient's caregivers about the immediate action to be taken in case of burns of more than 10% of body surface area. What reasons does the nurse provide for avoiding the use of ice on the burned body part? Select all that apply. Ice can cause hypothermia. Ice can cause vasoconstriction. Ice can stop further tissue damage. Ice can reduce blood flow to the burned area. Ice can increase the blood flow to the burned area.

Ice can cause hypothermia. Ice can cause vasoconstriction. Ice can reduce blood flow to the burned area. Ice can cause hypothermia, resulting in excessive cooling of the burned part and reduction of blood flow to that area. Ice can also cause vasoconstriction, thus causing the blood vessels supplying the burned area to narrow and supply less blood and oxygen. Applying ice does not prevent further tissue damage; instead, it decreases the blood supply, causing delayed wound healing. Ice does not increase the blood flow to the burned area; rather it decreases the blood flow due to vasoconstriction.

An 82-year-old patient is moving into an independent living facility. What is the best advice the nurse can give to the family to help prevent this patient from being accidentally burned in the new home? Cook for the patient Stop the patient from smoking Install tap water anti-scald devices Be sure the patient uses an open space heater

Install tap water anti-scald devices Installing tap water anti-scald devices will help prevent accidental scald burns that more easily occur in older people, because their skin becomes drier and the dermis thinner. Cooking for the patient may be needed at times of illness or in the future, but the patient is moving to an independent living facility, so at this time should not need this assistance. Stopping the patient 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 the patient's risk of being burned and would not be encouraged.

The patient in the emergent phase of a burn injury is being treated for pain. What medication should the nurse anticipate using for this patient? Intravenous (IV) morphine sulfate Subcutaneous (SQ) tetanus toxoid Intramuscular (IM) hydromorphone Oral (PO) oxycodone and acetaminophen

Intravenous (IV) morphine sulfate IV medications are used for burn injuries in the emergent phase to deliver relief rapidly and prevent unpredictable absorption as would occur with the IM route. Tetanus toxoid may be administered, but not for pain. The PO route is not used because gastrointestinal function is slowed or impaired because of shock or paralytic ileus, although oxycodone and acetaminophen may be used later in the patient's recovery.

A nurse is attending to a patient with burns. When considering the use of antibiotics, what factors does the nurse consider? Select all that apply. It is essential to check the patient for allergies to sulfa. Systemic antibiotics are routinely used to control burn wound flora. Silver-impregnated dressings can be left in place from 3 to 14 days. Silver sulfadiazine or mafenide acetate creams should never be used. Topical antimicrobial agents may be applied after the wound cleansing.

It is essential to check the patient for allergies to sulfa. Silver-impregnated dressings can be left in place from 3 to 14 days. Topical antimicrobial agents may be applied after the wound cleansing. The nurse should assess for a sulfa allergy, because some prescribed antibiotics may contain sulfa. Silver-impregnated dressings can be left in place from 3 to 14 days, depending on the patient's clinical situation and the particular product. Topical antimicrobial agents may be applied after the wound cleansing to facilitate healing, and then the affected area should be covered with a light dressing. Systemic antibiotics are not routinely used to control burn wound flora, because the burn eschar has little or no blood supply, and consequently, little antibiotic is delivered to the wound. Also, the routine use of systemic antibiotics increases the chance of developing multidrug-resistant organisms. Silver sulfadiazine and mafenide acetate creams are also used as burn antimicrobial creams.

When caring for a patient with an electrical burn injury, which prescription from the health care provider should the nurse question? Urine for myoglobin Lactated Ringer's at 25 mL/hr Mannitol 75 gm intravenous (IV) Sodium bicarbonate 24 mEq every 4 four hours

Lactated Ringer's at 25 mL/hr Electrical injury puts the patient at risk for myoglobinuria, which can lead to acute renal tubular necrosis (ATN). Treatment consists of infusing lactated Ringer's at 2 to 4 mL/kg/% total body surface area (TBSA), a rate sufficient to maintain urinary output at 75 to 100 mL/hr. An infusion rate of 25 mL/hr is not sufficient to maintain adequate urine output in prevention and treatment of ATN. Mannitol also can be used to maintain urine output. The urine would be monitored also for the presence of myoglobin. Sodium bicarbonate may be given to alkalinize the urine.

A nurse is attending to a patient with partial-thickness burns on the face, including corneal burns. What should she do to protect the eyes of the patient? Select all that apply. Use antibiotic ointments. Wait for laboratory reports. Instill methylcellulose eye drops. Arrange for ophthalmology examination. Inform the patient that periorbital edema is serious.

Use antibiotic ointments. Instill methylcellulose eye drops. Arrange for ophthalmology examination.

A burn patient is about to receive a dressing change. The patient has dressings over both feet and lower legs and is receiving a continuous infusion of hydromorphone. Which medication(s) is/are appropriate for the patient to receive before the dressing change is started? Select all that apply. Lorazepam, an anxiolytic Slow-release oral morphine Zolpidem, a sleep-inducing hypnotic Intravenous fentanyl, a short-acting opioid The patient will not need additional medication because the patient is receiving a continuous opioid infusion.

Lorazepam, an anxiolytic Intravenous fentanyl, a short-acting opioid Burn patients experience two kinds of pain: (1) continuous, background pain that might be present throughout the day and night; and (2) treatment-induced pain associated with dressing changes, ambulation, and rehabilitation activities. With background pain, a continuous intravenous (IV) infusion of an opioid (e.g., hydromorphone) allows for a steady, therapeutic level of medication. For treatment-induced pain, premedicate with an analgesic and an anxiolytic via the IV or oral route. For patients with an IV infusion, a potent, short-acting analgesic, such as fentanyl, often is effective. If an IV infusion is not present, slow-release, twice-a-day opioid medications (e.g., morphine) are indicated. The morphine would not be appropriate for this patient, because the patient is receiving an IV pain medication infusion. A sleeping pill is not appropriate at this time.

The patient in the acute phase of burn care has electrical burns on the left side of the body, type 2 diabetes mellitus, and a serum glucose level of 485 mg/dL. What should be the nurse's priority intervention to prevent a life-threatening complication of hyperglycemia for this burned patient? Maintain a neutral pH Maintain fluid balance Replace the blood lost Replace serum potassium

Maintain fluid balance This patient most likely is experiencing hyperosmolar hyperglycemic syndrome (HHS). HHS dehydrates a patient rapidly. Thus HHS combined with the massive fluid losses of a burn tremendously increases this patient's risk for hypovolemic shock and serious hypotension. This is clearly the nurse's priority , because the nurse must keep up with the patient's fluid requirements to prevent circulatory collapse caused by low intravascular volume. There is no mention of blood loss. Fluid resuscitation will help to correct the pH and serum potassium abnormalities.

The nurse is attending to a patient who is recovering from a full-thickness burn. The nurse understands that the patient is in a hypermetabolic state and needs nutritional support to promote wound healing and prevent malnutrition. What types of food and drinks should the nurse provide to the patient? Select all that apply. Tea Milkshakes Protein powder Low-protein food High-calorie food

Milkshakes Protein powder High-calorie food A patient with burns needs a high-calorie diet to compensate for the energy loss and increased protein intake to avoid malnutrition and delayed healing. Milkshakes have a lot of calories. Protein powder provides high protein. High-caloric food contains calories in large quantities and will help in the patient's recovery. Tea does not provide adequate quantities of calories and proteins. Low-protein food is not advised for a patient with burns, because the demand for protein is high to promote healing and a faster recovery.

While treating a patient who is administered initial emergency burn care and is in the acute phase of burns, what actions should the nurse perform as a part of respiratory therapy? Select all that apply. Avoid supplemental oxygen. Prepare for discharge home. Monitor for signs of complications. Continue assessing oxygenation needs. Continue to monitor respiratory status.

Monitor for signs of complications. Continue assessing oxygenation needs. Continue to monitor respiratory status. The nurse should monitor for signs of respiratory complications of burns to plan for appropriate respiratory therapy. Continue assessing oxygenation needs to plan for any alternations in oxygen supply. Continue to monitor the respiratory status to ensure proper breathing and circulation. Avoiding supplemental oxygen is not advisable, because oxygen needs may be assessed and started as required. Preparing for discharging the patient needs to be planned in the rehabilitation phase after the patient has recovered.

When teaching patients and caregivers about the strategies to reduce burn injuries, what essential instructions does the nurse give? Select all that apply. Perform outdoor activities during lightning storms. Never leave burning candles unattended or near windows or curtains. Ensure an electrical power source is shut off before beginning repairs. Check temperature of bath water with the back of hand or bath thermometer. Store chemicals in the lowest shelves to avoid mixing up with other household chemicals.

Never leave burning candles unattended or near windows or curtains. Ensure an electrical power source is shut off before beginning repairs. Check temperature of bath water with the back of hand or bath thermometer. Ensure that the electrical power source is shut off before beginning any repairs to avoid electrical burn injury. Never leave candles unattended or near open windows or curtains to avoid fire. Check the temperature of the bath water using the back of the hand or use the bath thermometer to avoid scalding burns, which commonly occur due to hot bathing water. Chemicals should be stored safely, preferably out of reach of children, in clearly written labels. Performing outdoor activities during lightning storms increases the risk of electrical injury from the ongoing lightning.

When planning for burn management, which patients should the nurse refer to a burn center? Select all that apply. Patients with hydrochloric acid burns Patients of all ages with first-degree burns Patients of all ages with third-degree burns Patients with 25% deep partial-thickness burns Patients with 5% superficial partial-thickness burns

Patients with hydrochloric acid burns Patients of all ages with third-degree burns Patients with 25% deep partial-thickness burns Patients suffering from hydrochloric acid burns, also known as chemical burns, should be referred to a burn center. Patients of all ages with third-degree burns are severe in condition and should be treated in a burn center. All patients with partial-thickness burns more than 10% should be referred to a burn center, because they are severe types of burns and need specialized treatment, care, and isolation. Patients of all ages with first-degree burns can be managed in the hospital and assessed. Patients with 5% superficial partial-thickness burns need not necessarily be referred and can be managed in the hospital.

A patient is brought to the emergency department (ED) with a history of inhalation burn injury. The patient has also sustained burns on the face, neck, and hands. Which actions would the nurse perform immediately? Select all that apply. Wait for laboratory reports. Observe for the next two hours. Provide 100% humidified oxygen. Observe for signs of respiratory distress. Check for evidence of inhalation of smoke.

Provide 100% humidified oxygen. Observe for signs of respiratory distress. Check for evidence of inhalation of smoke. Monitoring for signs of smoke or toxic chemical inhalation is an important step to evaluate burn victims. Also, assessing for signs of respiratory distress including increased agitation, anxiety, restlessness, or a change in the rate or character of breathing is important. Early treatment includes provision of 100% humidified oxygen and anticipating endotracheal intubation. Observing the patient for the next two hours does not help because treatment must begin at the earliest possible moment. In general, the patient suffering from burns on the face and neck may have mechanical obstruction caused by massive swelling of the tissues and requires intubation within one to two hours after the injury.

A patient who had a burn injury two days ago over 35% of the body is in the intensive care unit. The patient is intubated, on a mechanical ventilator, and fluid status is stable. Which of these interventions will the nurse anticipate for the patient's nutrition? Start total parenteral nutrition. Provide enteral tube feeding, starting at 20 mL/hour. Provide bolus enteral tube feedings four times a day. Feed at least 1500 calories/day in small, frequent meals.

Provide enteral tube feeding, starting at 20 mL/hour. Nonintubated patients with a burn of less than 20% total body surface area (TBSA) will generally be able to eat enough to meet their nutritional needs. Intubated patients and those with larger burns require additional support. Enteral feedings (gastric or intestinal) have almost entirely replaced parenteral feeding. Early enteral feeding, usually with smaller-bore tubes, preserves gastrointestinal (GI) function, increases intestinal blood flow, and promotes optimal conditions for wound healing. In general, begin the feedings slowly at a rate of 20 to 40 mL/hr and increase to the goal rate within 24 to 48 hours.

When teaching the patient about the use of range-of-motion (ROM), what explanations should the nurse give to the patient? Select all that apply. The exercises are the only way to prevent contractures ROM will show the patient that movement still is possible Active and passive ROM maintain function of body parts Movement facilitates mobilization of leaked exudates back into the vascular bed Active and passive ROM can be done only while the dressings are being changed

ROM will show the patient that movement still is possible Active and passive ROM maintain function of body parts Movement facilitates mobilization of leaked exudates back into the vascular bed Active and passive ROM maintain function of body parts and reassure the patient that movement still is possible are the explanations that should be used. Contractures are prevented with ROM as well as 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 already has taken analgesics, ROM can and should be done throughout the day.

A nurse is preparing a patient with partial-thickness burns on the hands for discharge from the burn care unit. What instructions should the nurse include when teaching the patient about rehabilitation at home? Select all that apply. Recommend exercises. Take low-dose antihistamines. Do not apply any creams on the wounds. Apply water-based creams on healed areas. Inform the patient that wound care is not required at home.

Recommend exercises. Take low-dose antihistamines. Do not apply any creams on the wounds. Apply water-based creams on healed areas. The nurse should advise the patient to take low-dose antihistamines, because these can be used at bedtime if itching persists. The nurse should be careful when applying cream on the healed areas. Only water-based creams that penetrate into the dermis should be used routinely on healed areas to keep the skin supple and well moisturized. This helps to decrease itching and flaking. The nurse should also encourage the patient to perform physical and occupational therapy routines and recommended exercises. The patient may have small, unhealed wounds, and, therefore, it is important to carry out dressing changes and wound care at home.

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

Refer the patient to a counselor for psychosocial support In the rehabilitation phase, the patient will work toward resuming a functional role in society, but frequently there are body image concerns and grieving for the loss of the way the body 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 per 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.

A patient with severe inhalation burns has been receiving treatment for 24 hours. When assessing the patient, what findings would indicate respiratory distress? Select all that apply. Restlessness Increased sleep Increased agitation Increased water intake Increased rate of breathing

Restlessness Increased agitation Increased rate of breathing Restlessness can result from respiratory distress, because the patient experiences disturbances in breathing. Increased agitation could result from the patient's attempts to compensate for an increasing oxygen demand and can be a sign of respiratory distress. An increased respiratory rate is a compensatory mechanism for the increased oxygen demands. It is a sign of impending respiratory distress and needs immediate attention. Increased sleep does not result from respiratory distress, because the patient becomes restless. Increased water intake is not specific to respiratory distress.

A patient with partial-thickness burns is now allowed oral feedings. What nursing interventions should the nurse perform to maintain the patient's nutrition? Select all that apply. Suggest low-calorie food. Suggest a high-protein diet. Suggest reduced fluid intake. Suggest a high-carbohydrate diet. Ask caregivers to get the patient's favorite food.

Suggest a high-protein diet. Suggest a high-carbohydrate diet. Ask caregivers to get the patient's favorite food. The patient may have a reduced appetite and may not like the food from the hospital. Therefore the caregivers can get the patient's favorite food. A swallowing assessment should be done by a speech pathologist before beginning with oral feeds. The patient should be provided with a high-protein diet to promote tissue healing and avoid malnutrition. A high-carbohydrate diet should be provided to meet the high metabolic demands. A low-calorie food may not meet the calorie requirements of the patient and leads to malnutrition and delayed wound healing. An adequate intake of fluids is essential for healing.

A patient with a burn inhalation injury is receiving albuterol for bronchospasm. What is the most important adverse effect of this medication for the nurse to manage? Tachycardia Hypokalemia Restlessness Gastrointestinal (GI) distress

Tachycardia Albuterol stimulates beta 2 receptors in the lungs to cause bronchodilation. However, it is a non-cardioselective agent so it also stimulates the beta 2 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.

A nurse is involved in the wound care of patients on the burn management unit. What precautions should the nurse take while performing wound care? Select all that apply. The nurse wears personal protective equipment. The nurse wears the same gown and masks for all patients. The nurse uses nonsterile gloves when applying ointments. The nurse uses sterile gloves when applying sterile dressings. The nurse uses nonsterile gloves when removing contaminated dressings.

The nurse wears personal protective equipment. The nurse uses sterile gloves when applying sterile dressings. The nurse uses nonsterile gloves when removing contaminated dressings. The nurse wears personal protective equipment like a disposable gown, mask, and gloves to prevent the spread of infection. The nurse uses sterile gloves when applying sterile dressings to prevent infection. The nurse uses nonsterile gloves when removing contaminated dressings for self-protection. The nurse should not wear the same gown and masks for all patients to avoid cross-contamination. It is necessary to wear new equipment before treating a new patient. The nurse should not necessarily use nonsterile gloves when applying ointments. Because the wound is open, sterile gloves should be used to prevent contamination.

While caring for a patient with burns, a nurse wraps the patient's wound with tubular elastic gauze. What are the reasons behind this action? Select all that apply. To decrease pain To prevent blistering To decrease itchiness To reduce venous return To enhance local immunity

To decrease pain To prevent blistering To decrease itchiness The interim pressure due to tubular elastic gauze decreases pain and itchiness and prevents blistering. It promotes venous return rather than reducing it. It does not enhance local immunity.

A patient with partial-thickness burns is being treated with zolpidem. What is the appropriate nursing response to the patient's caregivers when they ask about the purpose of administering this drug? Select all that apply. To promote sleep To reduce anxiety To promote wound healing To prevent thromboembolism To provide short-term amnesic effects

To promote sleep To reduce anxiety To provide short-term amnesic effects Zolpidem is a sedative-hypnotic medicine and is given to patients suffering from burns. Zolpidem promotes sleep, reduces anxiety, and provides short-term amnesic effects. Nutritional support is used to promote wound healing. Anticoagulants are used to prevent thromboembolism.

Why does the nurse apply enzymatic debriding agents to a patient with severe wounds? To decrease blood loss To remove the old microbial agent To protect the reepithelializing keratinocytes To remove dead tissue from the healthy wound bed

To remove dead tissue from the healthy wound bed Enzymatic debriding agents are made of natural products like collagen. Enzymatic debriding agents speed up the removal of dead tissue from the healthy wound bed. Skin grafting, a part of wound care, promotes massive blood loss in patients. To prevent this, topical application of epinephrine is advised. Washing the patient's wound with normal saline-moistened gauze removes the old antimicrobial agent. Paraffin gauze dressing protects the re-epithelializing keratinocytes from damage. This dressing resurfaces and closes the open bed wound.

Which precautions should the nurse take when changing a burn wound dressing? Select all that apply. Use sterile gloves when removing a contaminated dressing. Use sterile gloves when applying ointments and sterile dressings. Wear nonsterile, disposable gloves when washing the dirty wound. Keep the room cool to decrease the burning sensation of the wound. Always wear personal protective equipment, such as masks, gowns, and gloves.

Use sterile gloves when applying ointments and sterile dressings. Wear nonsterile, disposable gloves when washing the dirty wound. Always wear personal protective equipment, such as masks, gowns, and gloves. The nurse should use sterile gloves when applying ointment and sterile dressings. Nonsterile, disposable gloves should be worn when removing contaminated dressings and washing a dirty wound. The nurse should always wear personal protective equipment before the burn wounds are exposed. The room should be kept warm to prevent shivering in the patient.

When instructing a patient's caregiver about caring for a person with burns of more than 10% of total body surface area (TBSA), what does the nurse advise? Select all that apply. Wrap the patient in a blanket. Gently remove burned clothing. Leave adherent clothing in place. Apply ice all over the burned area. Leave the affected area open to air.

Wrap the patient in a blanket. Gently remove burned clothing. Leave adherent clothing in place. In case of severe burns, the patient should be wrapped in a blanket to avoid further contamination and to provide warmth. Burned clothing should be gently removed to prevent further tissue damage. Adherent clothing should be left in place until the patient is transferred to the hospital to avoid tissue damage. Leaving the affected area open to air can cause more contaminations and is not advisable. Applying ice all over the burned area can cause hypothermia and is not advisable.

A nurse plans to provide an antioxidant regimen for a patient with partial-thickness burns in the acute phase. Which are antioxidants and therefore should be included in the protocol? Select all that apply. Zinc Water Calcium Selenium Multivitamins

Zinc Selenium Multivitamins Zinc is an antioxidant and also a part of the antioxidant protocol because it supports cell growth and development. Selenium is used in the antioxidant protocol, because it helps to prevent cell damage. Multivitamins are a part of the antioxidant protocol because they help to compensate for the nutritional deficiencies of essential vitamins and minerals. Water is useful for the patient but does not form a part of the antioxidant protocol. Calcium is important to maintain strong bones and teeth, but it is not included in the antioxidant protocol.