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Test #4 Combo Burns

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b. the first priority is halting the severity of the burn, to limit the depth of the burn and quick action must be a priority.

The nurse plans care for a male pt who suffered thermal burns to the entire posterior aspect of his body when he fell on an outdoor grill. Which pt need is likely to be the primary problem of this pt in the emergent phase? a. maintain tissue oxygenation b. halt progression of the burn c. maintain intravascular volume d. prevent invasion of pathogens

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

The client who was the sole survivor in a house fire says, ''I feel so guilty. Why did I survive?'' What is the best response by the nurse? A) ''Do you want to pray about it?'' B) ''I know, and you will have to learn to adapt to a new body image.'' C) ''Tell me more.'' D) ''There must be a reason.''

Correct: C This response encourages therapeutic grieving.

The physician has prescribed Protonix (pantoprazole) for a client with burns. The nurse recognizes that the medication will help prevent the development of: A. Curling's ulcer B. Myoglobinuria C. Hyperkalemia D. Paralytic ileus

A. Curling's ulcer

Which laboratory result would be expected during the emergent phase of a burn injury? A. Glucose 100 mg/dL B. Potassium 3.5 mEq/L C. Sodium 142 mEq/L D. Albumin 4.2 gm/dL

A. Glucose 100 mg/dL

The injury the is least likely to result in a full-thickness burn is: A. sunburn B. scald injury C. chemical burn D. electrical burn

A. sunburn

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.

A. sunburn. Rationale The source of full-thickness burns can be a flame, scald, chemical, tar, or electric current. Reference: 475, Table 25-4

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

Ans: C Feedback: Elastic pressure garments are worn continuously (i.e., 23 hours a day).

The nurse caring for a patient who is recovering from full-thickness burns is aware of the patient's 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.

Ans: D Feedback: Exercise and the promotion of mobility can reduce the risk of contracture and hypertrophic scarring. Skin emollients are not normally used in the treatment of burns, and these do not prevent scarring. Steroids are not used to reduce scarring, as they also slow the healing process.

The patient sustained a full-thickness burn encompassing the entire right arm. What is the best indicator an escharotomy achieved its desired effect? A. Patient rates the pain at less than 4. B. Blood pressure remains above 120/80 mm Hg. C. Right fingers blanch with a 2-second refill. D. Patient maintains full range of motion for the right arm.

C. Circulation to the extremities can be severely impaired by deep circumferential burns and subsequent edema that impairs the blood supply. An escharotomy (electrocautery incision through the full-thickness eschar) is performed to restore circulation. Normal refill is less than 2 seconds.

During the rehabilitative phase, the client's burns become infected with pseudomonas. The topical dressing most likely to be ordered for the client is: A. Silver sulfadiazine (Silvadene) B. Poviodine (Betadine) C. Mafenide acetate (Sulfamylon) D. Silver nitrate

C. Mafenide acetate (Sulfamylon)

On the third post-burn day, the nurse finds that the client's hourly urine output is 26 ml. The nurse should continue to assess the client and notify the doctor for an order to: A. Decrease the rate of the intravenous infusion. B. Change the type of intravenous fluid being administered. C. Change the urinary catheter. D. Increase the rate of the intravenous infusion.

D. Increase the rate of the intravenous infusion

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

Using the Parkland formula calculate the fluid volume for a 154 woman who has sustained a 36% mixed deep partial and full thickness burn. How much fluid would you administer during the first 8 hours of fluid resuscitation? a.10,080 milliliters. b. 20,160 milliliters. c. 5,040 milliliters. d. 2520 milliliters.

c. 5,040 milliliters

A child has just been admitted to the pediatric burn unit. Currently, the child is being evaluated for burns to his chest and upper legs. He complains of thirst and asks for a drink. What is the most appropriate nursing action? a. give a small glass of clear liquid b. give a small glass of a full liquid c. keep the child NPO d. order a pediatric meal tray with extra liquids

c. Until a complete assessment and treatment plan are initiated, the child should be kept NPO. A complication of major burns is paralytic ileus, so until that has been ruled out, oral fluids should not be provided.

A nurse is caring for a client with a new donor site that was harvested to treat a burn. The nurse should position the client to: a. allow ventilation of the site b. make the site dependent c. avoid pressure on the site d. keep the site fully covered

c. a universal concern in the care of donor sites for burn care is to keep the site away from sources of pressure.

The condition of a client with extensive third degree burns begins to deteriorate. The nurse is aware that which type of shock may occur as a result of inadequate circulating blood volume that occurs with a burn injury? a. cardiogenic b. distributive c. hypovolemic d. septic

c. burns and the resulting low circulating fluid volume can cause hypovolemic shock.

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

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

The client arrives at the emergency department following a burn injury that occurred in the basement at home and an inhalation injury is suspected. Which of the following would the nurse anticipate to be prescribed for the client? a. 100% oxygen via an aerosol mask b. Oxygen via nasal cannula at 15L/min c. Oxygen via nasal cannula at 10L/min d. 100% oxygen via a tight fitting, non rebreather face mask

Using the Parkland Formula calculate the rate or rates of fluid administration if the total amount to be infused over 24 hours is 7853.76 mL of LR.

First 8 hours: 3900 ml at a rate of 487.5 (488 mL/hr) Next 16 hours: 3900 ml at a rate of 243.75 (244 mL/hr)

Grafts taken from one body and grafted onto another body are called what? A) Allograft B) Homograft C) Heterograft D) Autograft

HOMOGRAFT **Homografts are grafts derived from one person's body and used on another part of a different person's body.

Delete

Hct: 40%, urine-specific gravity 1.018, serum potassium 3.6 mEq/L

The patient you are caring for has an electrical burn and has developed thick eschar over the burn wound. 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

MAFENIDE ACETATE 10% (SULFAMYLON) HYDROPHILIC-BASED CREAM **Mafenide acetate 10% hydrophilic-based cream is the agent of choice for electrical burns because of its ability to penetrate thick eschar.

A client is admitted to a burn intensive care unit with extensive full thickness burns. What should be the nurse's initial concern? a. fluid status b. risk for infection c. body image d. level of pain

a. in early burn care, the client's greatest need has to do with fluid resuscitation because of large volume fluid loss through the damaged skin.

Which strategies does the nurse include when teaching a college student about fire prevention in the dormitory room? 1 Use space heaters to reduce electrical costs. 2 Check water temperature before bathing. 3 Do not smoke in bed. 4 Wear sunscreen.

3. Do not smoke in bed. Rationale: Smoking in bed increases the risk for fire because the person could fall asleep. Use of space heaters may increase the risk for fire, especially if they are knocked over and left unattended. Checking water temperature does not prevent fires, but it should be checked if the client has reduced sensation in the hands or feet. Sunscreen is advised to prevent sunburn.

Which clinical manifestation is indicative of wound healing for a client in the acute phase of burn injury? 1 Pale, boggy, dry, or crusted granulation tissue 2 Increasing wound drainage 3 Scar tissue formation 4 Sloughing of grafts

3. Scar tissue formation Rationale: Indicators of wound healing include the presence of granulation, reepithelization, and scar tissue formation. Pale, boggy, dry, or crusted granulation tissue is indicative of infection, as are increasing wound drainage and sloughing of grafts.

In the emergency department you carefully assess and observe pt. Which finding would be most concerning? 1. Urine output 20 mL/hr 2. Edema formation in upper airway 3. Pulmonary embolism resulting from inhalation injury 4. Development of hypothermia resulting from fluid evaporation from open wounds.

2. Edema formation in upper airway. R: upper airway results from inhalation injury to mouth, oropharynx, and/or larynx. Injury may be from thermal burns or inhalation of hot air, steam, or smoke. Mucosoal burns of the oropharynx and larynx are manifested by redness, blistering , and edema. The swelling can be massive and the onset is rapid. Maintaining airway is critical, pt will likely require early endotracheal (pref orotracheal) intubation to prevent the need for ER tracheostomy after respiratory problems become apparent.

The nurse is caring for a client with an electrical burn. Which structures have the greatest risk for soft tissue injury? A. Fat, tendons, and bones B. Skin and hair C. Nerves, muscle, and blood vessels D. Skin, fat, and muscle

A. Fat, tendons, and bones

A patient is admitted to the emergency department with first- and second-degree burns after being involved in a house fire. Which of the following assessment findings would alert you 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

a, c. 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, and cherry red skin color

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, the nurse should implement which of the following dietary choices? A. Full liquids only B. Whatever the patient requests C. High-protein and low-sodium foods D. High-calorie and high-protein foods

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

The nurse is caring for a client who sustained superficial partial thickness burns on the anterior lower legs and anterior thorax. Which of the following does the nurse expect to note during the resuscitation/emergent phase of the burn injury? a. decreased heart rate b. increased urinary output c. increased blood pressure d. elevated hematocrit levels

d. during the resuscitation/emergent phase, the hematocrit level increases to above normal because of hemoconcentration from the large fluid shift.

A client with full-thickness burns to the lower extremities has had emergent fasciotomies. What assessment parameter does the nurse monitor to evaluate the effectiveness of the fasciotomies? 1 Improved distal pulses 2 Reduced edema 3 Improved blood pressure 4 Reduced fluid resuscitation needs

1. Improved distal pulses Rationale: When edema is severe under the eschar of a full-thickness wound, blood flow to the area is compromised. Incisions, escharotomies, or fasciotomies are performed to relieve the growing pressure under the eschar. After the escharotomy or fasciotomy is performed, the assessment of improved perfusion is achieved by evaluating pulses distal to the procedure. Edema may not be reduced immediately due to inflammation from the incision. Blood pressure may be slightly elevated secondary to discomfort following the procedure. A fasciotomy does not necessarily indicate that fluid resuscitation will no longer be required.

To position a client's burned upper extremities appropriately, how does the nurse position the client's elbow? 1 In a neutral position 2 In a position of comfort 3 Slightly flexed 4 Slightly hyperextended

1. In a neutral position Rationale: The neutral (extended) position is the correct placement of the elbow to prevent contracture development. Placing the elbow in a position of comfort is not the best placement because the client then usually wants to flex the joint, which increases the risk for contracture development. The slightly flexed position increases the risk for contracture development. The slightly hyperextended position is not indicated and can be painful.

A client's burn injury was caused by a gasoline-fueled explosion. Which laboratory result does the nurse monitor closely for possible signs of organ injury? 1 Liver function tests 2 Arterial blood gases 3 Serum electrolytes 4 White blood cell count

1. Liver function tests Rationale: Burns caused by organic compounds such as those found in gasoline and chemical disinfectants are fat-soluble agents that, once absorbed by the skin, can have toxic effects on the kidneys and liver. The nurse should monitor labs that evaluate kidney and liver function. Monitoring arterial blood gas, serum electrolytes, and white blood cell count may be important as part of overall management of the burn-injured client; however, assessing laboratory results specific to kidney and liver function are the priority.

C. "Tell me more." Correct: This response encourages therapeutic grieving. Incorrect: A. "Do you want to pray about it?" Incorrect: Offering to pray with the client assumes spirituality of the client and does not allow for grieving. The nurse should never assume that the client is religious. B. "I know, and you will have to learn to adapt to a new body image." Incorrect: This response only serves to add stress to the client's situation. D. "There must be a reason." Incorrect: This response minimizes the grieving process by not allowing the client to express her or his concerns.

SHORT ANSWER 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 each arm is 9%.

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 patient's lung sounds. b. Determine the extent and depth of the burns. c. Infuse the ordered lactated Ringer's 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. DIF: Cognitive Level: Apply (application) REF: 452 | 455 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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

Ans: A Feedback: A large majority of burns occur in the home setting; educational interventions should address this epidemiologic trend.

Which factors indicate that the client's burn wounds are becoming infected? (Select all that apply.) A) Dry, crusty granulation tissue B) Elevated blood pressure C) Hypoglycemia D) Increasing wound drainage E) Swelling of the skin around wound F) Tachycardia

Correct: A,E, F A: Pale, boggy, dry, or crusted granulation tissue is a sign of infection. E: Swelling or edema of the skin around the wound is a sign of infection. F: Tachycardia is a systemic sign of infection.

The nurse is preparing the patient for mechanical debridement and informs the patient that this will involve: A) A spontaneous separation of dead tissue from the viable tissue B) Use of surgical scissors, scalpels or forceps to remove the 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

USE OF SURGICAL SCISSORS, SCALPELS OR FORCEPS TO REMOVE THE ESCHAR UNTIL THE POINT OF PAIN AND BLEEDING OCCURS **Mechanical debridement can be achieved through the use of surgical scissors, scalpels, or forceps to remove the eschar until the point of pain and bleeding occurs. Mechanical debridement can also be accomplished through the use of topical enzymatic debridement agents. The spontaneous separation of dead tissue from the viable tissue is an example of natural debridement. Early wound closure and shaving the burned skin layers are examples of surgical debridement.

The nurse is assessing a patient who has sustained a suspected deep partial thickness burn. In determining if this is a superficial or deep partial thickness injury, the nurse would anticipate which of the following? a. There is no change in capillary refill in the injured extremity. b. Hair follicles, sebaceous glands and epidermal sweat glands are intact. c. The wound appearance is a waxy white, with a wet surface and fluid filled blisters. d. The wound is very painful.

c. The wound appearance is a waxy white, with a wet surface and fluid filled blisters.

Which factors indicate that a client's burn wounds are becoming infected? Select all that apply. 1 Dry, crusty granulation tissue 2 Elevated blood pressure 3 Hypoglycemia 4 Swelling of the skin around the wound 5 Tachycardia 6. Increasing wound drainage

1. Dry, crusty granulation tissue 4. Swelling of the skin around the wound 5. Tachycardia Rationale: Pale, boggy, dry, or crusted granulation tissue is a sign of infection, as is swelling or edema of the skin around the wound. Tachycardia is a systemic sign of infection. Hypotension, not elevated blood pressure, and hyperglycemia, not hypoglycemia, are systemic signs of infection.

Which assessment does the nurse perform first on a client who has been admitted after an electrical injury with contact sites on the right hand and left foot? 1 Oxygen saturation 2 Electrocardiography 3 Depth of burn injury 4 Urine output

2. Electrocardiography Rationale: With contact sites on the right hand and foot, the current traveled in all body tissues between these two areas, with the potential to damage any tissue in the pathway. The heart is in this pathway and can suffer extensive damage to the muscle and the conduction system. Continuous electrocardiography (ECG) monitoring to determine heart health is the most important of the assessment areas listed.

In the acute phase of burn management, P.B. is at risk for stress-related complications. You carefully monitor her for signs and symptoms of _____________ ulcer and an increase in serum ____________ levels: 1. pressure, calcium 2. Curling's, calcium 3. pressure, glucose 4. Curling's, glucose

4. Curling's, glucose

A. in early burn care, the client's greatest need has to do with fluid resuscitation because of large volume fluid loss through the damaged skin.

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 patient's circulation. DIF: Cognitive Level: Apply (application) REF: 458 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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 patient's peripheral pulses distal to the dressing. D) Assist with passive range of motion exercises to ìsetî the new dressing.

Ans: C Feedback: Dressings can impede circulation if they are wrapped too tightly. The peripheral pulses must be checked frequently and burned extremities elevated. Dependent positioning does not need to be maintained. PRN analgesics should be administered prior to the dressing change. ROM exercises do not normally follow a dressing change.

Ranitidine (Zantac) is prescribed for a patient who had extensive burn injuries 5 days ago. Which information will the nurse collect to evaluate the effectiveness of the medication? a. Bowel sounds b. Stool frequency c. Stools for occult blood d. Percent of meals eaten

Correct Answer: C Rationale: H2-blockers are given to prevent Curling's ulcer in the patient who has suffered burn injuries. H2-blockers do not impact on bowel sounds, stool frequency, or appetite.

A patient with severe burns has fluid replacement ordered using the Parkland formula. The initial rate of administration is 1050 ml/hr. The nurse would expect that 18 hours after the burn occurred, the rate of the fluid administration should be _____ ml/hr. a. 263 b. 350 c. 525 d. 1050

Correct Answer: C Rationale: 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 525 ml/hr.

Which of these laboratory results requires the most rapid action by the nurse who is caring for a patient who suffered a large burn 48 hours ago? a. Serum sodium, 146 mEq/L b. BUN 36 mg/dl c. Serum potassium 6.2 mEq/dl d. Hct 52%

Correct Answer: C Rationale: Hyperkalemia can lead to fatal bradycardias 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 nurse determines that fluid replacement for a patient with major burns is adequate, based on the finding of a. daily weight unchanged from admission. b. BP of 90/58. c. urinary output of 40 ml/hr. d. total fluid intake equal to urinary output.

Correct Answer: C Rationale: When fluid intake is adequate, the urine output will be at least 30 to 50 ml/hr. The patient's weight and ratio of intake to output are not useful in this situation because of the effects of third spacing and evaporative fluid loss. A BP of 90/58 is an indication of hypovolemia in a patient who has had a major burn injury.

A patient is admitted to the burn unit with burns of the head, neck, chest, and back following a garage fire. Upon admission to the unit, the nurse auscultates wheezes in the patient's lungs. One hour later, the wheezes cannot be heard, and lung sounds are decreased. The most appropriate action by the nurse is to a. place the patient in high-Fowler's position. b. encourage the patient to cough and auscultate the lungs again. c. document the results and continue to monitor the ventilation. d. notify the health care provider about the breath sounds.

Correct Answer: D Rationale: The patient with burns of the face and neck and with decreased breath sounds will require intubation and ventilatory assistance, and the health care provider should be notified so that this can be rapidly accomplished. 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.

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

Correct answers: a, d, e Rationale: 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 client with a burn injury who is receiving sulfadiazine (Silvadene) to the burn wounds. Which best describes the goal of topical antimicrobials? A) Reduction of bacterial growth in the wound and prevention of systemic sepsis B) Prevention of cross-contamination from other clients in the unit C) Enhanced cell growth D) Reduced need for a skin graft

Correct: A Topical antimicrobials such as sulfadiazine are an important intervention for infection prevention in burn wounds.

Which clinical manifestation is indicative of wound healing for the client in the acute phase of burn injury? A) Pale, boggy, dry, or crusted granulation tissue B) Increasing wound drainage C) Scar tissue formation D) Sloughing of grafts

Correct: C Indicators of wound healing include the presence of granulation, re-epithelization, and scar tissue formation.

During the care of the patient with a burn in the acute phase, which new interventions should the nurse expect to do after the patient progressed from the emergent phase? a. begin IV fluid replacement b. monitor for signs of complications c. access and manage pain and anxiety d. discuss possible reconstructive surgery

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.

During the emergent phase of burn injury, the nurse assesses for the presence of hypovolemia. In burn patients, hypovolemia occurs primarily as a result of a. Blood loss from injured tissue. b. Third spacing of fluid into fluid-filled vesicles. c. Evaporation of fluid from denuded body surfaces. d. Capillary permeability with fluid shift to the interstitium.

d Rationale: Hypovolemic shock is caused by a massive shift of fluids out of the blood vessels as a result of increased capillary permeability. Water, sodium, and plasma proteins move into interstitial spaces and other surrounding tissue.

You are working with unlicensed assistive personnel (UAP). Which nursing activities included in the care plan are best delegated to UAP? (Select all that apply.) 1. Empty and record pt hourly urine output. 2. Reapply sequential compression devices following pt bath. 3. Assess pt pain relief following administration of morphine. 4. Administer subcutaneous insulin based on pt capillary blood glucose reading. 5. Perform capillary blood glucose monitoring. 6. Perform the dressing changes on pt graft sites.

1, 2, 5 Correct. R: UAP may be taught to empty urinary drainage, apply sequential compression devices, and perform capillary blood glucose monitoring. However, UAP may not be delegated duties that require assessment or decision making.

What is the best method to prevent autocontamination for the client with burns? A) Change gloves when handling wounds on different areas of the body. B) Ensure that the client is in isolation therapy. C) Restrict visitors. D) Watch for early signs of infection.

What is the best method to prevent autocontamination for the client with burns? A) Change gloves when handling wounds on different areas of the body. Feedback: CORRECT Correct: Gloves should be changed when handling wounds on different areas of the body and between handling old and new dressings. B) Ensure that the client is in isolation therapy. Feedback: INCORRECT Incorrect: Isolation therapy methods are used to prevent cross-contamination rather than autocontamination. C) Restrict visitors. Feedback: INCORRECT Incorrect: Restricting visitors helps prevent cross-contamination, not autocontamination. D) Watch for early signs of infection. Feedback: INCORRECT Incorrect: Watching for early signs of infection does not prevent contamination. Points Earned: 0.0/1.0 Correct Answer(s): A

A burn patient is transitioning from the acute phase of the injury to the rehabilitation phase. The patient tells the nurse "I can't wait to have surgery to reconstruct my face so I look normal again." What would be the nurse's best response? A) "You know, nothing can be done until your scars mature. It is something the doctor will talk to you about in the first few years after discharge." B) "That is something for you to talk to your doctor about." 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) "You will have most of these scars for the rest of your life."

YOU KNOW, NOTHING CAN BE DONE UNTIL YOUR SCARS MATURE. IT IS SOMETHING THE DOCTOR WILL TALK TO YOU ABOUT IN THE FIRST FEW YEARS AFTER DISCHARGE **Burn reconstruction is a treatment option after all scars have matured and is discussed within the first few years after injury. Options B and C are true statements but not the best statements. The nurse does not know for sure how much reconstruction can be done.

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 of the following would provide the most reliable indicator for determining the adequacy? a. vital signs b. urine output c. mental status d. peripheral pulses

b. successful or adequate fluid resuscitation in the client is signaled by stable vital signs, adequate urine output, palpable peripheral pulses and clear sensorium.

The patient in the acute phase of burn care has electrical burns on the left side of her 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? a. replace the blood lost b. maintain a neutral pH c. maintain fluid balance d. replace serum potassium

c. This patient is most likely experiencing hyperosmolar hyperglycemic syndrome (HHS). HHS dehydrates a patient rapidly. Thus 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 victim of an industrial accident has chemical spilled on his face and body. The chemical, which has a pH of 7.51, is flushed with water by paramedics. What is the most important information for the receiving nurse to obtain about the pt from the paramedics? a. containment of chemical b. duration of water flushing c. other injuries of the victim d. specific location of accident

d. The nurse must know where the accident occurred to determine if the pt was rescued from an enclosed space. If so, the pt is at high risk for an inhalation injury because the enclosure concentrates the noxious fumes making an inhalation injury more likely.

A client with burns has developed sepsis. Which sign or symptom in the client indicates fungal infection? 1 Severe disorientation 2 Occasional diarrhea 3 Hypothermia 4 Lethargy

2. Occasional diarrhea Rationale: Sepsis, often present due to open burn wounds, can be caused due to fungi, gram-positive bacteria, and gram-negative bacteria. Signs and symptoms of fungal infection are the presence of occasional diarrhea, mild disorientation, and fever. Severe disorientation and lethargy are symptoms of gram-positive bacterial infection. Hypothermia is a symptom of gram-negative bacterial infection.

A nursing student is caring for a client with open wound burns. Which nursing interventions does the nursing student provide for this client? Select all that apply. 1 Provides cushions and rugs for comfort 2 Performs frequent handwashing 3 Places plants in the client's room 4 Performs gloved dressing changes 5 Uses disposable dishes

2. Performs frequent handwashing 4. Performs gloved dressing changes 5. Uses disposable dishes Rationale: Handwashing is the most effective technique for preventing infection. Gloves should be worn when changing dressings to reduce the risk for infection. Equipment is not shared with other clients to prevent the risk for infection; this includes the use of disposable dishes. Cushions and rugs are difficult to clean and may harbor organisms, so are not provided. To avoid exposure to pseudomonas, having plants or flowers in the room is prohibited.

A patient in the rehabilitation phase of the burn injury is setting goals with the nurse. What goals would be appropriate at this time? (Mark all that apply.) A) Increased participation in activities of daily living B) Increased understanding of the planned follow-up care C) Increased control of treatment D) Adjustment to alterations in lifestyle E) Recognition of complications

A, B, D INCREASED PARTICIPATION IN ADLs, INCREASED UNDERSTANDING OF THE PLANNED FOLLOW-UP CARE, ADJUSTMENT TO ALTERATIONS IN LIFESTYLE **The major goals for the patient include increased participation in activities of daily living; increased understanding of the injury, treatment, and planned follow-up care; adaptation and adjustment to alterations in body image, self-concept, and lifestyle; and absence of complications.

Your patient is in the acute phase of a burn injury. One of the nursing diagnoses on the plan of care is ineffective coping due to burn injury and altered body image. What interventions can you institute to help this patient cope more effectively? (Mark all that apply.) A) Promote truthful communication B) Allowing the patient to set specific expectations C) Assist the patient in practicing appropriate strategies D) Stop the patient's manipulation of staff E) Give positive reinforcement when appropriate

A,C,E PROMOTE TRUTHFUL COMUNICATION, ASSIST THE PATIENT IN PRACTICING APPROPRIATE STRATEGIES, GIVE POSITIVE REINFORCEMENT WHEN APPROPRIATE **The nurse can assist the patient to develop effective coping strategies by setting specific expectations for behavior, promoting truthful communication to build trust, helping the patient practice appropriate strategies, and giving positive reinforcement when appropriate. The nurse should set specific expectations, not the patient. Each staff member needs to stop the manipulation of the patient with the involved staff member.

The nursing instructor is going over burn injuries. The instructor tells the students that the nursing care priorities for a patient with a burn injury include wound care, nutritional support, and prevention of complications such as infection. Based upon these care priorities, the instructor is most likely discussing a patient in what phase of burn care? A) Emergent B) Immediate resuscitative C) Acute D) Rehabilitation

ACUTE **The acute or intermediate phase of burn care follows the emergent/resuscitative phase and begins 48 to 72 hours after the burn injury. During this phase, attention is directed toward continued assessment and maintenance of respiratory and circulatory status, fluid and electrolyte balance, and gastrointestinal function. Infection prevention, burn wound care (ie, wound cleaning, topical antibacterial therapy, wound dressing, dressing changes, wound debridement, and wound grafting), pain management, and nutritional support are priorities at this stage and are discussed in detail in the following sections. Priorities during the emergent or immediate resuscitative phase include first aid, prevention of shock and respiratory distress, detection and treatment of concomitant injuries, and initial wound assessment and care. The priorities during the rehabilitation phase include prevention of scars and contractures, rehabilitation, functional and cosmetic reconstruction, and psychosocial counseling.

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. DIF: Cognitive Level: Apply (application) REF: 455 | 457 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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. DIF: Cognitive Level: Apply (application) REF: 452 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

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

Ans: A Feedback: Airway obstruction caused by upper airway edema can take as long as 48 hours to develop. Changes detected by x-ray and arterial blood gases may occur as the effects of resuscitative fluid and the chemical reaction of smoke ingredients with lung tissues become apparent.

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 patient's 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)

Ans: A Feedback: As edema increases, pressure on small blood vessels and nerves in the distal extremities causes an obstruction of blood flow and consequent ischemia. This complication is similar to compartment syndrome. Referred pain, cellulitis, and VTE are not noted complications that occur distal to the injury site.

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

Ans: A Feedback: Burn reconstruction is a treatment option after all scars have matured and is discussed within the first few years after injury. Even though this is not a nursing responsibility, the nurse should still respond appropriately to the patient's query. It is true that the patient will not realistically look like he or she used to, but this does not instill hope.

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 patient's 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

Ans: A Feedback: The goal of treatment is to provide a long-acting analgesic that will provide even coverage for this long-term discomfort. It is helpful to use escalating doses when initiating the medication to reach the level of pain control that is acceptable to the patient. The use of patient-controlled analgesia (PCA) gives control to the patient and achieves this goal. Patients cannot normally achieve adequate pain control without the use of opioids, and parenteral administration is usually required.

A patient's burns have required a homograft. During the nurse's most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurse's most appropriate response? A) Perform mechanical dÈbridement 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.

Ans: B Feedback: An infected graft may need to be removed, thus the care provider should be promptly informed. ROM exercises will not resolve this problem and the nurse would not independently perform dÈbridement.

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

Ans: B Feedback: Mafenide acetate 10% hydrophilic-based cream is the agent of choice when there is a need to penetrate thick eschar. Silver products do not penetrate eschar; Acticoat is a type of silver dressing.

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

Ans: C Feedback: To prevent the complication of contractures, the nurse will establish a goal to maintain position of joints in alignment. Gentle range of motion exercises and a consult to PT and OT for exercises and positioning recommendations are also appropriate interventions for the prevention of contractures. Joint alignment is not maintained specifically for preventing neuropathy, wound breakdown, or heterotopic ossification.

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 patient's arm? A) Superficial partial-thickness B) Deep partial-thickness C) Full partial-thickness D) Full-thickness

Ans: D Feedback: A full-thickness burn involves total destruction of the epidermis and dermis and, in some cases, underlying tissue as well. Wound color ranges widely from white to red, brown, or black. The burned area is painless because the nerve fibers are destroyed. The wound can appear leathery; hair follicles and sweat glands are destroyed. Edema may also be present. Superficial partial-thickness burns involve the epidermis and possibly a portion of the dermis; the patient will experience pain that is soothed by cooling. Deep partial-thickness burns involve the epidermis, upper dermis, and portion of the deeper dermis; the patient will complain of pain and sensitivity to cold air. Full partial thickness is not a depth of burn.

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

Ans: D Feedback: Pain is inevitable during recovery from any burn injury. Pain in the burn patient has been described as one of the most severe causes of acute pain. Management of the often-severe pain is one of the most difficult challenges facing the burn team. While the other nursing diagnoses listed are valid, the presence of pain may contribute to these diagnoses. Management of the patient's pain is the priority, as it may have a direct correlation to the other listed nursing diagnoses.

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 patient's psychosocial state.

Ans: D Feedback: Recovery from burns can be psychologically challenging; the nurse's assessments must address this reality. Fluid and electrolyte imbalances are infrequent during the rehabilitation phase of recovery. Burns are not typically a health problem that tends to recur; the experience of being burned tends to foster vigilance.

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

Ans: D Feedback: Systemic effects are a result of several variables. However, TBSA and wound severity are considered the major factors that affect the presence or absence of systemic effects.

While performing a patient's 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 patient's 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.

Ans: D Feedback: The patient may experience feelings of anger. The anger may be directed outward toward those who escaped unharmed or toward those who are now providing care. While drug reactions, complications, and frustrating inconsistencies in care cannot be automatically ruled out, it is not uncommon for anger to be directed at caregivers.

Which is the best diet choice for the patient during the acute burn phase? A. Fresh lettuce salad, Jell-O B. Hamburger, spaghetti C. Low-fat milk, cookie D. Raw apple, coffee

B. Hamburger, spaghetti Rationale Burn patients are in a hypermetabolic state and need high-protein and high-carbohydrate foods to have adequate calories and protein to promote healing. Reference: 486

The CVP reading of a client with partial thickness burns is 6 mm H2O. The nurse recognizes that the client: A. Needs additional fluids B. Has a normal CVP reading C. May show signs of congestive failure D. Would benefit from a diuretic

B. Has a normal CVP reading

A patient has 25% TBSA burned from a car fire. His wounds have been debrided and covered with a silver-impregnated dressing. Your priority intervention for wound care is to A. reapply a new dressing without disturbing the wound bed. B. observe the wound for signs of infection during dressing changes. C. apply cool compresses for pain relief between dressing changes. D. wash the wound aggressively with soap and water three times each day.

B. observe the wound for signs of infection during dressing changes. infection risk

Knowing the most common causes of household fires, which of the following prevention strategies would the nurse focus on when teaching about fire safety? a. set how water temp at 140 F b. use only hardwired smoke detectors c. encourage regular home fire exit drills d. never permit older adults to cook unattended.

The patient walks to the emergency department in clothing saturated with alkali solution after a can of drain cleaner exploded at home a few minutes earlier. What nursing action is most important? A. Assess the patient's lungs. B. Administer a tetanus immunization. C. Wash the skin with copious amounts of water. D. Obtain a set of vital signs.

C. Wash the skin with copious amounts of water. Rationale Alkali burns, such as caused by oven and drain cleaners, damage the tissue because the chemicals adhere and cause protein hydrolysis and liquefaction. Patients with chemical burns should have clothing removed and the affected area flushed with copious amount of water. Reference: 479, Table 25-8

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 factors does the nurse know are considered when determining the depth of burn? A) Causative agent B) Visual observation of burned area C) Area of body burned D) Circumstances of the accident

CAUSATIVE AGENT **The following factors are considered in determining the depth of a burn: how the injury occurred, causative agent (such as flame or scalding liquid), temperature of the burning agent, duration of contact with the agent, and thickness of the skin. To determine the depth of the burn you do not take into consideration you visual observation of the burned area, how much of the body is burned, or the circumstances of the accident.

A patient who was found unconscious in a burning bedroom and has burns to the lower legs is assessed by the nurse in the emergency department. The nurse notes that the patient's face is bright red. Which of these actions should the nurse take first? a. Elevate the legs on pillows. b. Place the patient on 100% O2 using a non-breather mask. c. Assess for singed nasal hair and dark oral mucous membranes. d. Insert 2 large-bore IV lines.

Correct Answer: B Rationale: The patient's 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 actions to correct gas exchange.

An employee spilled industrial acids on the arms and legs at work. Before transporting the individual to the hospital, the occupational nurse at the facility should a. cover the affected area with dry, sterile dressings. b. flush the burned area with large amounts of tap water. c. place cool compresses on the area of exposure. d. apply an alkaline solution to the affected area.

Correct Answer: B Rationale: With chemical burns, the initial action is to remove the chemical from contact with the skin as quickly as possible. 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.

To maintain a positive nitrogen balance in a major burn, the patient must: a. eat a high-protein, low-fat, high-carbohydrate diet b. increase normal caloric intake by about three times c. eat at least 1500 calories/day in small, frequent meals d. eat rice and whole wheat for the chemical effect on nitrogen balance.

Correct answer: a Rationale: 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 therapeutic measure used to prevent hypertrophic scarring during rehabilitation phase of burn recover is: a. applying pressure garments b. repositioning the patient every 2 hours c. performing active ROM at least every 4 hours d. massaging the new tissue with water-based moisturizers

Correct answer: a Rationale: 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.

A patient has 25% TBSA burned from a car fire. His wounds have been debrided and covered with a silver-impregnated dressing. The nurse's priority intervention for wound care would be to: a. reapply a new dressing without disturbing the wound bed b. observe the wound for signs of infection during dressing changes c. apply cool compresses for pain relief in between dressing changes d. wash the wound aggressively with soap and water three times a day.

Correct answer: b Rationale: Infection is the most serious threat with regard to further tissue injury and possible sepsis.

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 vascular space c. sequestering of sodium and water in interstitial fluid d. hemolysis of red blood cells from large volumes of rapidly administered fluid

Correct answer: c Rationale: During the emergency phase, sodium rapidly shifts to the interstitial spaces and remains there until edema formation ceases.

The client with burn injuries states, ''I feel so helpless.'' Which nursing intervention is most helpful for this client? A) Encourages participation in wound care B) Encourages visitors C) Tells the client that he or she will be fine D) Tells the client that his or her feelings are normal

Correct: A Encouraging participation in wound care will offer the client some sense of control.

The nurse is reviewing a medication record for an older adult client recently admitted to the burn unit with severe burns to the upper body from a house fire. The nurse plans to contact the health care provider if the client is receiving which medication? A) Furosemide (Lasix) B) Digoxin (Lanoxin) C) Dopamine (Inotropin) D) Morphine sulfate

Correct: A Furosemide, a diuretic, generally is not given to improve urine output for burn clients. Diuretics decrease circulating volume and cardiac output by pulling fluid from the circulating blood to enhance diuresis. This reduces blood flow to other vital organs.

Correct: A Gloves should be changed when handling wounds on different areas of the body and between handling old and new dressings.

The newly admitted client has deep partial-thickness burns. The nurse expects to see which clinical manifestations? A) Painful red and white blisters B) Painless, brownish-yellow eschar C) Painful reddened blisters D) Painless black skin with eschar

Correct: A Painful red and white blisters accompany a deep partial-thickness burn

To position the client's burned upper extremities appropriately, how does the nurse position the client's elbow? A) In a neutral position B) In a position of comfort C) Slightly flexed D) Slightly hyperextended

Correct: A The neutral position is the correct placement of the elbow to prevent contracture development.

Which assessment information about a 60-kg client admitted 12 hours ago with a full-thickness burn over 30% of the total body surface area will be of greatest concern to the nurse? A) Bowel sounds are absent B) The pulse oximetry level is 91% C) The serum potassium level is 8.1 mEq/L D) Urine output since admission is 370mL

Correct: C An elevated serum potassium level can cause cardiac arrest.

In assessing the client in the rehabilitative phase of burn therapy, which nursing diagnosis does the nurse anticipate? A) Acute Pain B) Excess Fluid Volume C) Disturbed Body Image D) Risk for Infection

Correct: C In the rehabilitative phase of burn therapy, the client is discharged and his or her life is not the same. A priority problem of reduced self-image is expected.

Which strategies does the nurse include when teaching the college student about fire prevention in their dormitory room? A) use of space heaters. B) Check water temperature before a bath or shower. C) Do not smoke in bed. D) Wear sunscreen.

Correct: C Smoking in bed increases the risk for fire because the person could fall asleep

The client is being admitted with burn injuries. Which priority does the nurse anticipate within the first 24 hours? A) Body temperature assessment B) Emotional support C) Fluid resuscitation D) Urine output monitoring

Correct: C The client will require fluid resuscitation because fluid does not stay in the vessels after a burn injury.

The nurse is caring for the client with burns. Which question does the nurse ask the client and family to assess their coping strategies? A) ''Do you support each other?'' B) ''How do you plan to manage this situation?'' C) ''How have you handled similar situations before?'' D) ''Would you like a counselor?''

Correct: C This question assesses whether the client's and the family's coping strategies may be effective.

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 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

EARLY AND ENTERAL FEEDING **If the intestinal mucosa receives some type of protection against permeability change, infection could be avoided. Early enteral feeding is one step to help avoid this increased intestinal permeability and prevent early endotoxin translocation. Antibiotics are seldom prescribed prophylactically because of the risk of promoting resistant strains of bacteria. A bowel cleansing procedure would not be ordered for this patient. The administration of stool softeners would not assist in avoiding increased intestinal permeability and prevent early endotoxin translocation.

Which statement made by a client who experienced 45% total body surface area burns to the face, neck, chest, and arms indicates positive adjustment to the injury? 1 "I am planning on returning to work gradually so that I don't get too tired." 2 "I am working with my family so they can do all of the chores I used to do." 3 "I hope the home care nurse can change my dressings so that I do not have to look at my wounds." 4 "My wife and I have decided to go to movies instead of baseball games so that people can't see me."

1. "I am planning on returning to work gradually so that I don't get too tired." Rationale: Reintegrating into the family situation, assuming the roles and responsibilities performed before the injury, and gradual reintegration back into the community and work are positive signs of beginning successful adjustment. Not looking at the wounds and not participating in family life are indicators of poor adjustment. Although it is good that the client is venturing outside of the home, the fact that he wants to remain unseen is a less positive indicator of adjustment.

Knowing the most common causes of household fires, which prevention strategy would the nurse focus on when teaching about fire safety? a. Set hot water temperature at 140 degrees F b. Use only hardwired smoke detectors c. Encourage regular home fire exit drills d. Never permit older adults to cook unattended

1. Correct answer: c Rationale: A risk-reduction strategy for household fires is to encourage regular home fire exit drills. 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). 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 only if cognitive alterations are observed.

A client who was successfully resuscitated after a burn injury begins diuresis 3 days after admission. For which assessment findings does the nurse observe during this phase of the injury? Select all that apply. 1 Hyponatremia 2 Hyperkalemia 3 Hypotension 4 Weight gain 5 Metabolic acidosis 6 Metabolic alkalosis

1. Hyponatremia 3. Hypotension 5. Metabolic acidosis Rationale: Fluid remobilization starts at about 24 hours postinjury and the diuretic phase begins at about 48-72 hours after burn injury. Interstitial fluids mobilize and diuresis results in hypotension, hyponatremia, hypokalemia, weight loss, and possible metabolic acidosis from loss of bicarbonate in the urine and increased metabolism.

Which category of burn injury reflects deep partial-thickness burns affecting 20% of the total body surface area (TBSA)? 1 Moderate burn 2 Major burn 3 Minor burn 4 Severe burn

1. Moderate burn Rationale: Deep partial-thickness burns affecting 15% to 25% TBSA are classified as moderate burns. Partial-thickness burns affecting more than 25% of TBSA are classified as major burns. Deep partial-thickness burns affecting less than 15% of TBSA are considered minor burns. Burns are categorized as three types: major, minor, and moderate; there is no "severe" burn category.

A client with a severe burn injury is prescribed gentamicin sulfate (Gentamar). Which nursing intervention is most appropriate related to this medication? 1 Monitoring creatinine clearance 2 Administering a pain medication 3 Evaluating white blood cell count 4 Assessing the wound for infection

1. Monitoring creatinine clearance Rationale: Gentamicin sulfate (Gentamar) is a medication prescribed to decrease the risk for infection for clients who have suffered a severe burn injury. While administering this medication to a client, it is essential that the nurse monitor the client's creatinine clearance because this drug can adversely affect kidney function and cause nephrotoxicity. Although the nurse would administer pain medication, evaluate white blood cell count, and monitor this client for wound infection, these are not interventions that are needed while administering gentamicin sulfate.

The nurse is caring for a client with a burn injury who is receiving sulfadiazine (Silvadene) to the burn wounds. Which best describes the goal of topical antimicrobials? 1 Reduction of bacterial growth in the wound and prevention of systemic sepsis 2 Prevention of cross-contamination from other clients in the unit 3 Enhanced cell growth 4 Reduced need for a skin graft

1. Reduction of bacterial growth in the wound and prevention of systemic sepsis Rationale: Topical antimicrobials such as sulfadiazine are an important intervention for infection prevention in burn wounds. Topical antimicrobials such as sulfadiazine do not prevent cross-contamination from other clients in the unit. They do not enhance cell growth nor do they minimize the need the need for a skin graft.

A client who was rescued from an explosion is provided fluid resuscitation. Which factor should be assessed in the client after providing fluid resuscitation? 1 Serum sodium levels 2 Hemoglobin levels 3 Alanine aminotransferase 4 Serum cholesterol levels

1. Serum sodium levels Rationale: Renal failure is caused due to the accumulation of large amounts of proteins and myoglobin in the kidneys as a result of muscle damage. Fluid resuscitation must be provided to the client in order to maintain a rate of 30 to 50 mL of urine output. Serum sodium levels, serum creatinine levels, and specific gravity of the urine must be monitored every hour after providing fluid resuscitation to the client—it helps to assess kidney function. Hemoglobin levels can be monitored in case of anemia; hemoglobin levels are not an indicator of kidney function. Alanine aminotransferase is an enzyme that is secreted by the liver and is an indicator of hepatic functioning.

A client with a burn injury due to a house fire is admitted to the burn unit. The client's family asks the nurse why the client received a tetanus toxoid injection on admission. What is the nurse's best response to the client's family member? 1 "The last tetanus injection was less than 5 years ago." 2 "Burn wound conditions promote the growth of Clostridium tetani." 3 "The wood in the fire had many nails, which penetrated the skin." 4 "The injection was prescribed to prevent infection from pseudomonas.

2. "Burn wound conditions promote the growth of Clostridium tetani." Rationale: Burn wound conditions promote the growth of Clostridium tetani, and all burn clients are at risk for this dangerous infection. Tetanus toxoid enhances acquired immunity to C. tetani, so this agent is routinely given when the client is admitted to the hospital. Regardless of when the last tetanus injection is given, it is still given on admission to prevent C. tetani. The fact that there were many nails in the wood in the fire is irrelevant. Tetanus toxoid injection does not prevent pseudomonas infection.

An older client has suffered a 45% body surface area burn from a house fire. Which complication is the client at greater risk of developing because of age-related changes? 1 Ineffective pain management 2 Acute kidney injury 3 Anxiety 4 Gastric stress ulcers

2. Acute kidney injury Rationale: The older client is at greater risk of developing shock and acute kidney injury after a burn injury because resuscitation efforts may be limited due to underlying cardiac dysfunction that occurs with aging. Ineffective pain management, anxiety, and gastric stress ulcers can occur in any client with a burn injury.

A client with an electrical burn is being resuscitated with fluids. The nurse reports a decrease in urine output from 50 mL/hr to 15 mL/hr. Which order does the nurse question? 1 500-mL fluid bolus 2 Furosemide 40 mg IV 3 Increase IV fluids by 100 mL/hr for 4 hours 4 Send urinalysis for myoglobin

2. Furosemide 40 mg IV Rationale: A common mistake in treatment for burn injury is administering diuretic agents during the fluid resuscitation phase in an effort to increase urine output. A reduction in urine output is usually the result of decreased perfusion. The appropriate intervention is to increase fluid resuscitation to improve renal perfusion and subsequent urine output. Sending a urinalysis for myoglobin is important because myoglobin levels are elevated in clients with electrical burns and can cause renal damage in large amounts.

The nurse is reviewing the orders for a client admitted with 25% body surface area burns. Which order does the nurse clarify with the health care provider? 1 Daily weights 2 Hold omeprazole (Prilosec) 3 Fentanyl (Actiq) 50 mcg IV every 4 hours PRN for pain 4 Activity as tolerated

2. Hold omeprazole (Prilosec) Rationale: The nurse should question the order to hold omeprazole, a proton pump inhibitor agent. Clients with burn injury are at increased risk of developing an acute gastroduodenal ulcer (Curling's ulcer) within the first 24 hours after a severe burn injury because of reduced blood flow to the gastrointestinal tract and mucosal lining damage. Proton pump inhibitors and H2-histamine blocking agents along with early enteral feedings are important interventions to prevent this complication. Daily weights, IV opioid agents for pain management, and activity orders are appropriate for clients with burn injuries.

Which alteration observed in a client rescued from a fire indicates pulmonary injury? 1 Exhaling through the mouth 2 Inability to swallow fluids 3 Reporting dizziness 4 Coughing with sputum

2. Inability to swallow fluids Rationale: The client who has been rescued from a fire may have pulmonary injury due to inhalation of carbon monoxide. Pulmonary injury is characterized by difficulty in swallowing and a brassy cough. Exhaling through the mouth is not an indication of pulmonary injury. Even in deep breathing or in congestion, clients exhale through the mouth. The client may have dizziness due to an imbalance in body fluids and electrolytes. Carbonaceous sputum indicates pulmonary injury or airway obstruction. Cough with sputum can be seen with infections or chronic obstructive pulmonary disorder (COPD); it does not indicate pulmonary injury.

A client is in the resuscitation phase of burn injury. Which route does the nurse use to administer pain medication to the client? 1 Intramuscular 2 Intravenous 3 Sublingual 4 Topical

2. Intravenous Rationale: During the resuscitation postburn phase, the intravenous route is used for giving opioid drugs because of problems with absorption from the muscle and stomach. When these agents are given by the intramuscular or subcutaneous route, they remain in the tissue spaces and do not relieve pain. In addition, when edema is present, all doses are rapidly absorbed at once when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics. Because the skin is too damaged, the sublingual route and the topical route are not indicated for administering drugs to the client in the resuscitation phase of burn injury.

Which method must be employed during hydrotherapy for the debridement of a wound in the client with acid burns? 1 The wound must be cleaned three times a week. 2 Nonviable tissue must be removed by forceps. 3 The wounds are rinsed with cold water. 4 Small blisters are opened with scissors.

2. Nonviable tissue must be removed by forceps. Rationale: Nonviable tissue must not be touched with bare hands; it must be removed using scissors and forceps to avoid infection. The wound must be cleaned once or twice a day to avoid microbial infections. The wound must be rinsed with water at room temperature because it enhances the circulation of blood due to vasodilation. Small blisters must not be opened because they help in wound healing and act as covers and protective barriers.

A client with burns to the face, neck, upper body, and hands from a house fire starts wheezing on exhalation and reports difficulty swallowing about 4 hours after the injury. What is the nurse's best first action? 1 Ensure that the client remains NPO. 2 Notify the Rapid Response Team. 3 Slow the IV infusion rate. 4 Raise the head of the bed.

2. Notify the Rapid Response Team. Rationale: The client is at high risk for an inhalation injury from the circumstances of the burn (enclosed space and burns to the face, neck, upper body, and hands). The wheezing and difficulty swallowing indicate possible pulmonary injury and oral and throat swelling. This client is in danger of losing a patent airway and needs emergency intubation immediately.

A client arrives in the emergency department with burns as a result of spilling boiling water while cooking. Which assessment finding of the burned areas on the tops of both hands and chest does the nurse use as a basis to document a probable full-thickness injury? 1 Most of the wounded area is red. 2 Thrombosed blood vessels are visible beneath the skin surface. 3 The area does not blanch when firm pressure is applied. 4 The client reports that the area hurts when touched.

2. Thrombosed blood vessels are visible beneath the skin surface. Rationale: The presence of thrombosed blood vessels beneath the skin surface is a strong indication of a full-thickness injury. Partial-thickness injuries can directly damage more superficial blood vessels, but do not cause thrombosis of deeper vessels. Red areas can be associated with nearly any depth of burn injury. The presence of pain is not a good indicator of burn depth. Although full-thickness injuries have much less pain than partial-thickness injuries, pain may still be present. Deep partial-thickness injuries may or may not blanch with firm pressure.

Which dietary guideline must be followed for a client with a large burn area? 1 The diet must be low-calorie and high-protein. 2 The client must not be encouraged to have solid foods. 3 Feeding can be started within 4 hours of fluid resuscitation. 4 The nutritional value of the diet must be less than 5000 kcal/day.

3. Feeding can be started within 4 hours of fluid resuscitation. Rationale: After starting fluid resuscitation feeding can begin for the client within 4 hours—this helps to provide stamina and energy to the client. The client requires a high amount of protein and calories for wound healing and tissue repair. The client must be encouraged to have solid food, to ingest as many calories as possible. A client who has a large burn area requires a diet with a nutritional value of more than 5000 kcal/day for effective body functioning.

A client receives a prescription for collagenase (Santyl) for treatment of burns. To decrease the risk of infection, the nurse expects what else to be included on the client's plan of care? 1 A narcotic 2 A loop diuretic 3 Polysporin powder 4 Blood glucose monitoring

3. Polysporin powder Rationale: Autolysis is the process of tissue disintegration using the client's own cellular enzymes. In this process, collagenase (Santyl) is applied directly to the burn wound, which may increase the client's risk of infection. Therefore, polysporin powder should be used with collagenase (Santyl) to prevent risk of infection. Narcotic pain medications are prescribed to reduce pain, not decrease the risk for infection. Diuretics enhance dieresis and reduce blood supply to vital organs, causing severe hypovolemic shock. Blood glucose levels are measured during the resuscitation phase and do not decrease the client's risk for infection.

Which assessment is the nurse's highest priority in caring for a client in the acute phase of burn injury? 1 Bowel sounds 2 Muscle strength 3 Signs of infection 4 Urine output

3. Signs of infection Rationale: The client with burn injury is at risk for infection as a result of open wounds and reduced immune function. Burn wound sepsis is a serious complication of burn injury, and infection is the leading cause of death during the acute phase of recovery. Assessing bowel sounds, assessing muscle strength, and assessing urine output are not the priority during the acute phase of burn injury.:

A client has a 32% burn injury to the chest, arms, and legs with the following assessment data. After reviewing the assessment data, the nurse contacts the provider to evaluate the client for the possible development of which potential complication associated with burn injury? Data: RR 32, Temp 101.5, HR 110, BP 110/62, urine output<30mL/hr, BG 220 vomiting x1, pt alert, anxious, wounds converted from partial thickness to full thickness in some areas, increased burn wound drainage 1 Acute respiratory distress syndrome 2 Hypovolemic shock 3 Systemic infection 4 Acute kidney injury

3. Systemic infection Rationale: Burn-injured clients are at increased risk of local and systemic infection. Signs of infection include elevated temperature, tachycardia, tachypnea, decreased blood pressure, hyperglycemia, decreased gastric function, altered mental status, and the conversion of burn wounds to include increased drainage and poor healing. Acute respiratory distress syndrome, hypovolemic shock, and acute kidney injury are potential complications for burn-injured clients, but the assessment data in the client's chart do not indicate these conditions.

The client is a burn victim who is noted to have increasing edema and decreased urine output as a result of the inflammatory compensation response. What does the nurse do first? 1 Administer a diuretic. 2 Provide a fluid bolus. 3 Recalculate fluid replacement based on time of hospital arrival. 4 Titrate fluid replacement.

4. Titrate fluid replacement. Rationale: The intravenous fluid rate should be adjusted on the basis of urine output plus serum electrolyte values (titration of fluids). A common mistake in treatment is giving diuretics to increase urine output. Diuretics do not increase cardiac output, but actually decrease circulating volume and cardiac output by pulling fluid from the circulating blood volume to enhance diuresis. Fluid boluses are avoided because they increase capillary pressure and worsen edema. Fluid replacement formulas are calculated from the time of injury, not from the time of arrival at the hospital.

You have just reported to the burn unit to start your shift. Four new patients have been admitted in the past 12 hours. 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 healthy male burned over 36% of his body in a car accident C) A 39-year-old female with myasthenia gravis burned over 18% of her body D) A 60-year-old male burned over 16% of his body in a brush fire

A 4 YEAR OLD SCALD VICTIM BURNED OVER 24% FO THE BODY **Young children and the elderly continue to have increased morbidity and mortality when compared to other age groups with similar injuries and present a challenge for burn care. This is an important factor when determining the severity of injury and possible outcome for the patient.

c. Using the rule of nines, the face and neck together encompass 4.5% of the body area; the right upper arm encompasses 9% of the body area; and the entire anterior trunk encompasses 18% of the body area. Since 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, the nurse would correctly calculate the extent of this patient's burns to cover approximately 22.5% of the total body surface area.

A patient is admitted with first- and second-degree burns covering the face, neck, entire right upper extremity, and the right anterior trunk area. Using the rule of nines, the nurse would calculate the extent of these burns as being A. 9%. B. 18%. C. 22.5%. D. 36%.

b. albuterol stimulates beta adrenergic receptors in the lungs to cause bronchodilation and is nonselective and also causes receptors in the heart to increase heart rate.

A pt who has an inhalation injury is receiving albuterol (Ventolin) for bronchospasm. What is the most important adverse effect of this medication for the nurse to manage? a. gi distress b. tachycardia c. restlessness d. hypokalemia

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? a. Apply sterile gauze dressing. b. Document wound appearance. c. Apply silver sulfadiazine cream. d. Administer IV fentanyl (Sublimaze). e. Clean wound with saline-soaked gauze.

ANS: D, E, C, A, B Because partial-thickness burns are very painful, the nurse's first action should be to administer pain medications. The wound will then be cleaned, antibacterial cream applied, and covered with a new sterile dressing. The last action should be to document the appearance of the wound. DIF: Cognitive Level: Apply (application) REF: 465 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient who has been receiving hospice care for 3 months tells the LPN he has decided he wants to return to active treatment of his disease. What should the LPN do? A. Encourage the patient to discuss his desire with his physician B. Tell the patient that he cannot change his goals once hospice care has been initiated C. Check his medication supply for any leftover medications he was taking during treatment D. Explain to the patient that since he is terminal, treatment will not help the course of his disease

ANS: A

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

ANS: A Feedback: Anticipated fluid and electrolyte changes that occur during the emergent/resuscitative phase of burn injury include sodium deficit, potassium excess, base-bicarbonate deficit, and elevated hematocrit. PT does not typically decrease.

Which nursing intervention is likely to be most helpful in providing adequate nutrition while a client is recovering from a thermal burn injury? a. Allowing the client to eat whenever he or she wants b. Beginning parenteral nutrition high in calories c. Including 3000 kcal/day of calories with meals d. Providing a low-protein, high-fat diet

ANS: A Clients should request food whenever they think they can eat, not just according to the hospital's standard meal schedule. The nurse needs to work with a dietitian to provide a high-calorie, high-protein diet to help with wound healing. Clients who can eat solid foods should ingest as many calories as possible; they may need as many as 5000 kcal/day. Specific caloric requirements can be determined by the dietitian. Parenteral nutrition may be given as a last resort because it is invasive and can lead to infectious and metabolic complications

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 patient's caloric needs. Parenteral nutrition increases the infection risk, does not help preserve gastrointestinal function, and is not routinely used in burn patients.

The nurse has been teaching a client about skin grafting procedures. What statement indicates that the client needs further education about allografts? a. "Because the graft is my own skin, there is no chance it won't 'take.'" b. "For a few days after surgery, the donor sites will be painful." c. "I will have some scarring in the area where the skin is removed." d. "I am still at risk for infection after the procedure until the burn heals."

ANS: A Factors other than tissue type, such as circulation and infection, influence whether and how well a graft will work. The client should be prepared for the possibility that not all grafting procedures will be successful. Donor sites will be painful after surgery, scarring can occur in the area where skin is removed for grafting, and the client is still at risk for infection.

A client who is admitted after a thermal burn injury has the following vital signs: blood pressure, 70/40; heart rate, 140 beats/min; and respiratory rate, 25 breaths/min. He is pale, and it is difficult to find pedal pulses. Which action does the nurse take first? a. Begin intravenous fluid resuscitation. b. Check pulses with a Doppler device. c. Obtain a complete blood count (CBC). d. Obtain an electrocardiogram (ECG)

ANS: A Hypovolemic shock is a common cause of death in the emergent phase of clients with serious injury. Fluids can treat this problem. ECG and CBC will be taken to ascertain whether a cardiac or bleeding problem is causing these vital signs. However, these are not actions that the nurse would take immediately. Checking pulses would indicate perfusion to the periphery, but this is not an immediate nursing action.

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? a. The new nurse uses clean latex 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 administers PRN fentanyl (Sublimaze) IV to a patient 5 minutes before a dressing change. d. The new nurse calls the health care provider for a possible insulin order when a nondiabetic patient's serum glucose is elevated.

ANS: A Sterile gloves should be worn when applying medications or dressings to a burn. Hypothermia is an indicator of possible sepsis, and cultures are appropriate. Nondiabetic patients may require insulin because stress and high calorie intake may lead to temporary hyperglycemia. Fentanyl peaks 5 minutes after IV administration, and should be used just before and during dressing changes for pain management

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 patient's 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 patient's 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

When providing care for a client with an acute burn injury, which nursing intervention is most important to prevent infection by autocontamination? a. Avoid sharing equipment such as blood pressure cuffs between clients. b. Change gloves between wound care on different parts of the client's body. c. Use the closed method of burn wound management for all wound care. d. Use proper and consistent handwashing by all members of the staff.

ANS: B Autocontamination is the transfer of microorganisms from one area to another area of the same client's body, causing infection of a previously uninfected area. Although all techniques listed can help reduce the risk for infection, only changing gloves between carrying out wound care on different parts of the client's body can prevent autocontamination.

A client has severe burns around the right hip. Which position does the nurse instruct the nursing assistant to use to maintain maximum function of this joint? a. Hip maintained in 30-degree flexion b. Hip at zero flexion with leg flat c. Knee flexed at 30-degree angle d. Leg abducted with foam wedge

ANS: B Maximum function for ambulation occurs when the hip and the leg are maintained at full extension with neutral rotation. Although the client does not have to spend 24 hours in this position, he or she should be in this position (in bed or standing) longer than with the hip in any degree of flexion.

A client has experienced an electrical injury of the lower extremities. Which priority assessment data should be obtained from this client? a. Range of motion in all extremities b. Heart rate, rhythm, and electrocardiogram (ECG) c. Respiratory rate and pulse oximetry d. Orientation to time, place, and person

ANS: B The airway is not at any particular risk with this injury. Therefore, respiratory rate and pulse oximetry are not priority assessments. Electrical current travels through the body from the entrance site to the exit site and can seriously damage all tissues between the two sites. Early cardiac damage from electrical injury includes irregular heart rate and rhythm, and ECG changes. Range-of-motion and neurologic assessments are important; however, the priority is to make sure that the heart rate and rhythm are adequate to support perfusion to the brain and other vital organs.

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? 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 results 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 patient's 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. DIF: Cognitive Level: Apply (application) REF: 459 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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. DIF: Cognitive Level: Apply (application) REF: 462 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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? 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. "It is really too early to know how much your life will be changed by the burn." d. "Why do you feel that way? You will be able to adapt as your recovery progresses."

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 are accurate, but do not acknowledge the anxiety and depression that the patient is expressing. DIF: Cognitive Level: Apply (application) REF: 470-471 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

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? 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. DIF: Cognitive Level: Understand (comprehension) REF: 454 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

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. DIF: Cognitive Level: Analyze (analysis) REF: 452 | 456 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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. DIF: Cognitive Level: Apply (application) REF: 458 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A nurse is reviewing the white blood cell count with differential for a client receiving chemotherapy for cancer. Which finding alerts the nurse to the possibility of sepsis? a. Total white blood cell count is 9000/mm3. b. Lymphocytes outnumber basophils. c. "Bands" outnumber "segs." d. Monocyte count is 1800/mm3.

ANS: C Normally, mature segmented neutrophils ("segs") are the major population of circulating leukocytes, constituting 55% to 70% of the total white blood cell count. Less than 3% to 5% of circulating white blood cells should be the less mature band neutrophils. A left shift occurs when the bone marrow releases more immature neutrophils than mature neutrophils. This condition indicates severe infection with possible sepsis and must be explored further.

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? a. Monitor urine output every 4 hours. b. Continue to monitor the laboratory results. c. Increase the rate of the ordered IV solution. d. Type and crossmatch for a blood transfusion.

ANS: C The patient's laboratory data show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake 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. On admission to a burn unit, the urine output would be monitored more often than every 4 hours; likely every 1 hour. DIF: Cognitive Level: Apply (application) REF: 257 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

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. DIF: Cognitive Level: Apply (application) REF: 458 | 464-465 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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 right arm in a position of comfort. b. Avoid the use of sustained-release narcotics. c. Teach about the purpose of tetanus immunization. d. Apply water-based cream to burned areas frequently.

ANS: D 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. DIF: Cognitive Level: Apply (application) REF: 468-469 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

The nurse is caring for a dying client who becomes very agitated. What is the nurse's best response? a. Use music therapy to promote relaxation. b. Increase the dose of intravenous opioids. c. Provide a second antipsychotic medication. d. Assess the client for urinary retention.

ANS: D Dying clients become agitated when they are in pain or have some discomfort. Before administering medications or other therapies to decrease discomfort, the nurse should assess for potential causes of discomfort including urinary retention.

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

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? 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.

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? a. "I'm glad the scars are only temporary." b. "I will avoid using a pillow, so my neck will be OK." c. "I bet my boyfriend won't even want to look at me anymore." d. "Do you think dark beige makeup foundation would cover this scar on my cheek?"

ANS: D The willingness to use strategies to enhance appearance is an indication that the disturbed body image is resolving. Expressing feelings about the scars indicates 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 indicates 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. DIF: Cognitive Level: Apply (application) REF: 469 TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity

A client with open burn wounds begins to have diarrhea. The client is found to have a below-normal temperature, with a white blood cell count of 4000/mm3. Which action by the nurse is most appropriate? a. Continue to monitor the client. b. Increase the temperature in the room. c. Increase the rate of intravenous fluids. d. Prepare to do a workup for sepsis.

ANS: D These findings are associated with systemic Gram-negative infection and sepsis. To verify that sepsis is occurring, cultures of the wound and blood must be taken to determine the appropriate antibiotic to be started. Continuing just to monitor the situation can lead to septic shock. Increasing the temperature in the room may make the client more comfortable, but the priority is finding out whether the client has sepsis and treating it before it becomes a shock situation. The rate of intravenous fluids may be increased to replace fluid losses associated with diarrhea, but this is not the priority action.

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

Ans: A Feedback: If the intestinal mucosa receives some type of protection against permeability change, infection could be avoided. Early enteral feeding is one step to help avoid this increased intestinal permeability and prevent early endotoxin translocation. Antibiotics are seldom prescribed prophylactically because of the risk of promoting resistant strains of bacteria. A bowel cleansing procedure would not be ordered for this patient. The administration of stool softeners would not assist in avoiding increased intestinal permeability and prevent early endotoxin translocation.

An emergency department nurse has just received a patient with burn injuries brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the patient's body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period? A) Administer IV fluids B) Administer broad-spectrum antibiotics C) Administer IV potassium chloride D) Administer packed red blood cells

Ans: A Feedback: Pathophysiologic changes resulting from major burns during the initial burn-shock period include massive fluid losses. Addressing these losses is a major priority in the initial phase of treatment. Antibiotics and PRBCs are not normally administered. Potassium chloride would exacerbate the patient's hyperkalemia.

A patient is brought to the emergency department with a burn injury. The nurse knows that the first systemic event after a major burn injury is what? A) Hemodynamic instability B) Gastrointestinal hypermotility C) Respiratory arrest D) Hypokalemia

Ans: A Feedback: The initial systemic event after a major burn injury is hemodynamic instability, which results from loss of capillary integrity and a subsequent shift of fluid, sodium, and protein from the intravascular space into the interstitial spaces. This precedes GI changes. Respiratory arrest may or may not occur, largely depending on the presence or absence of smoke inhalation. Hypokalemia does not take place in the initial phase of recovery.

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

Ans: A Feedback: Young children and the elderly continue to have increased morbidity and mortality when compared to other age groups with similar injuries and present a challenge for burn care. This is an important factor when determining the severity of injury and possible outcome for the patient.

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.

Ans: A, C, E Feedback: The nurse can assist the patient to develop effective coping strategies by setting specific expectations for behavior, promoting truthful communication to build trust, helping the patient practice appropriate strategies, and giving positive reinforcement when appropriate. The patient may benefit from being able to make decisions regarding his or her care. Benzodiazepines may be needed for short-term management of anxiety, but they are not used to enhance coping.

The nurse is preparing the patient for mechanical dÈbridement 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

Ans: B Feedback: Mechanical dÈbridementcan be achieved through the use of surgical scissors, scalpels, or forceps to remove the eschar until the point of pain and bleeding occurs. Mechanical dÈbridement can also be accomplished through the use of topical enzymatic dÈbridement agents. The spontaneous separation of dead tissue from the viable tissue is an example of natural dÈbridement. Shaving the burned skin layers and early wound closure are examples of surgical dÈbridement.

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

Ans: B Feedback: Patient and family education is a priority during rehabilitation. There should be no fluid and electrolyte imbalances in the rehabilitation phase. The presence of impaired thermoregulation or infection would suggest that the patient is still in the acute phase of burn recovery.

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 nurse's most appropriate response to the family member? A) ìHe's on a calorie-restricted diet in order to divert energy to wound healing.î B) ìHis body has consumed his fat deposits for fuel because his calorie intake is lower than normal.î C) ìHe actually hasn't lost weight. Instead, there's been a change in the distribution of his body fat.î D) ìHe lost many fluids while he was being treated in the emergency phase of burn care.î

Ans: B Feedback: Patients lose a great deal of weight during recovery from severe burns. Reserve fat deposits are catabolized as a result of hypermetabolism. Patients are not placed on a calorie restriction during recovery and fluid losses would not account for weight loss later in the recovery period. Changes in the overall distribution of body fat do not occur.

A home care nurse is performing a visit to a patient's home to perform wound care following the patient's 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

Ans: B Feedback: Post-traumatic stress disorder (PTSD) is the most common psychiatric disorder in burn survivors, with a prevalence that may be as high as 45%. As a result, it is important for the nurse to assess for this complication of burn injuries. Psychosis, delirium, and dementia are not among the noted psychiatric and psychosocial complications of burns.

A nurse who provides care on a burn unit is preparing to apply a patient's 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.

Ans: C Feedback: After removing the old ointment from the wound bed, the nurse should apply a layer of ointment 1/16-inch thick using clean gloves. The wound would not be irrigated after application of new ointment.

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.

Ans: C Feedback: After the flames or heat source have been removed or extinguished, the burned area and adherent clothing are soaked with cool water briefly to cool the wound and halt the burning process. Cool water is the best first-aid measure. Ice and butter are contraindicated. Appropriate first aid necessitates touching the burn.

A patient experienced a 33% TBSA burn 72 hours ago. The nurse observes that the patient's 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 patient's IV fluid infusion. B) Report the patient's 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.

Ans: C Feedback: As capillaries regain integrity, 48 or more hours after the burn, fluid moves from the interstitial to the intravascular compartment and diuresis begins. This is an expected development and does not require a reduction in the IV infusion rate or the administration of NaCl. Diuresis is not suggestive of AKI.

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 nurse's 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.

Ans: C Feedback: As the Biobrane gradually separates, it is trimmed, leaving a healed wound. When the Biobrane dressing adheres to the wound, the wound remains stable and the Biobrane can remain in place for 3 to 4 weeks. There is no need to reinforce the Biobrane nor to remove it and apply a new dressing. There is not likely any need to notify the physician for further orders.

The current phase of a patient's 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

Ans: C Feedback: The acute or intermediate phase of burn care follows the emergent/resuscitative phase and begins 48 to 72 hours after the burn injury. During this phase, attention is directed toward continued assessment and maintenance of respiratory and circulatory status, fluid and electrolyte balance, and gastrointestinal function. Infection prevention, burn wound care (i.e., wound cleaning, topical antibacterial therapy, wound dressing, dressing changes, wound dÈbridement, and wound grafting), pain management, and nutritional support are priorities at this stage. Priorities during the emergent or immediate resuscitative phase include first aid, prevention of shock and respiratory distress, detection and treatment of concomitant injuries, and initial wound assessment and care. The priorities during the rehabilitation phase include prevention of scars and contractures, rehabilitation, functional and cosmetic reconstruction, and psychosocial counseling.

A patient arrives in the emergency department after being burned in a house fire. The patient's 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%

Ans: C Feedback: When estimating the percentage of body area or burn surface area that has been burned, the Rule of Nines is used: the face is 4.5%, and the forearm is 9% for a total of 18% in this patient.

A patient's burns are estimated at 36% of total body surface area; fluid resuscitation has been ordered in the emergency department. After establishing intravenous access, the nurse should anticipate the administration of what fluid? A) 0.45% NaCl with 20 mEq/L KCl B) 0.45% NaCl with 40 mEq/L KCl C) Normal saline D) Lactated Ringer's

Ans: D Feedback: Fluid resuscitation with lactated Ringers (LR) should be initiated using the American Burn Association's (ABA) fluid resuscitation formulas. LR is the crystalloid of choice because its composition and osmolality most closely resemble plasma and because use of normal saline is associated with hyperchloremic acidosis. Potassium chloride solutions would exacerbate the hyperkalemia that occurs following burn injuries.

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 ìcool the burn.î How should the nurse cool the burn? A) Apply ice to the site of the burn for 5 to 10 minutes. B) Wrap the patient's 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.

Ans: D Feedback: Once the burn has been sustained, the application of cool water is the best first-aid measure. Soaking the burn area intermittently in cool water or applying cool towels gives immediate and striking relief from pain, and limits local tissue edema and damage. However, never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns. Butter is contraindicated.

You are caring for a patient with superficial partial-thickness burns on the face sustained within the last 12 hours. On assessment, you expect to find which symptom? A. Blisters B. Reddening of the skin C. Destruction of all skin layers D. Damage to sebaceous glands

B. Reddening of the skin Rationale The clinical appearance of superficial partial-thickness burns includes erythema, blanching with pressure, and pain and minimal swelling with no vesicles or blistering during the first 24 hours. Reference: 475

Several clients have been brought to the ED after an office building fire. Which client is at greatest risk for inhalation injury? A) Woman who is frantically explaining what happened to the nurse B) Man who suffered burn injuries in a closed space C) Woman with burns to the extremities D) Man with thick, tan-colored sputum

B. Young adult who suffered burn injuries in a closed space Correct: The client who suffered burn injuries in a closed space is at greatest risk for inhalation injury because the client breathed a greater concentration of confined smoke. Incorrect: A. Middle-aged adult who is frantically explaining to the nurse what happened Incorrect: Clients typically have some type of respiratory distress. However, the client is talking without difficulty, which shows that the client has minimal respiratory distress. C. Adult with burns to the extremities Incorrect: Extensive burns to the hands and face, not the extremities, would be a greater risk. D. Older adult with thick, tan-colored sputum Incorrect: Sputum would be carbonaceous, not tan, if the client had suffered inhalation injury.

To maintain a positive nitrogen balance in a major burn, the patient must A. increase normal caloric intake by about three times. B. eat a high-protein, low-fat, high-carbohydrate diet. C. eat at least 1500 calories per day in small, frequent meals. D. eat rice and whole wheat for the chemical effect on nitrogen balance.

B. eat a high-protein, low-fat, high-carbohydrate diet. Rationale 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 delayed healing. Reference: 486

C. Fluid resuscitation Correct: The client will require fluid resuscitation because fluid does not stay in the vessels after a burn injury. Incorrect: A. Body temperature assessment Incorrect: Assessment of body temperature is not the priority for this client. B. Emotional support Incorrect: Although emotional support is important, this is not the priority during the resuscitation phase for this client. D. Sterile dressing changes Incorrect: Although sterile dressing changes are important, this is not the priority for this client.

C. Right fingers blanch with a 2-second refill. Rationale Circulation to the extremities can be severely impaired by deep circumferential burns and subsequent edema that impairs the blood supply. An escharotomy (electrocautery incision through the full-thickness eschar) is performed to restore circulation. Normal refill is less than 2 seconds. Reference: 480

When caring for a patient with an electrical burn injury, you should question a health care provider's order for A. 75 g of IV mannitol. B. urine for myoglobulin. C. lactated Ringer's at 25 mL/hr. D. 24 mEq of sodium bicarbonate every 4 hours.

C. lactated Ringer's at 25 mL/hr. Rationale 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 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 should be monitored for the presence of myoglobin. An infusion rate of 25 mL/hr is not sufficient to maintain adequate urine output in the prevention and treatment of ATN. Reference: 474

Which of these patients is most appropriate for the burn unit charge nurse to assign to an RN staff nurse 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 and parenteral nutrition (PN) b. A 45-year-old patient who has just come back to the unit after having a cultured epithelial autograft to the chest c. A 60-year-old patient who has twice-daily burn débridements and dressing changes to partial-thickness facial burns d. A 63-year-old patient who has blebs under an autograft on the thigh and has an order for bleb aspiration

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

During the early emergent phase of burns, the nurse will anticipate giving opioid analgesics by the IV route so that a. the medications will be rapidly effective. b. less frequent administration is needed. c. larger doses of medications can be given. d. respiratory depression can be easily treated.

Correct Answer: A Rationale: Because medications administered by the oral or IM routes will not be rapidly effective, the nurse should administer medications IV. IV medications are rapidly metabolized, and frequent administration may be necessary. The dosage is not determined by the route, but by its effectiveness. The ease with which respiratory depression can be corrected is not a factor in choosing the route for medication administration in a burn patient.

Two weeks after admission for major burns, a patient is continuing to lose weight despite a high-carbohydrate, high-protein diet. The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements. In planning nursing interventions, the best between-meal snack for the patient would be a. eggnog. b. bagel. c. nuts. d. crackers and cheese.

Correct Answer: A Rationale: Eggnog has the highest protein, calorie, and carbohydrates of the choices. Because the patient with a major burn is likely to be anorexic, it is important that the patient's foods be nutrient dense.

A patient in the acute phase of burn injury requires frequent hydrotherapy sessions for wound débridement. To evaluate for complications of hydrotherapy, the nurse will plan to closely monitor a. serum sodium level. b. lung sounds. c. pulse quality. d. daily urine output.

Correct Answer: A Rationale: Hydrotherapy leads to loss of sodium from open burn areas into the bath water, which is hypotonic. Lung sounds, pulse quality, and urine output are not directly affected by hydrotherapy, although these assessments are also part of patient care.

A 21-year-old patient who has deep partial-thickness facial and neck burns has a nursing diagnosis of disturbed body image. The nurse evaluates that patient outcomes for this nursing diagnosis are met when the patient a. starts to use make-up to cover up the scars. b. expresses concern about the scar appearance. c. realizes that scarring is temporary. d. avoids using a pillow under the head.

Correct Answer: A Rationale: The willingness to use strategies to enhance appearance is an indication that the problem has resolved. Expressing concern about the scars indicates a willingness to discuss the scars but does not indicate that the disturbed body image is resolved. Scarring from deep partial-thickness burns is permanent, although some improvement in scar appearance may occur. Avoiding using a pillow will help prevent contractures, but it does not address the problem of disturbed body image.

Which action should the nurse take first when caring for a patient who has just arrived in the emergency department with facial and chest burns caused by a house fire? a. Ringer's solution b. Lung sounds c. Size and depth d. Ordered opioid

Correct Answer: B Rationale: 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 of these nursing actions should be accomplished first for a patient who has suffered a burn injury while working on an electrical power line? a. Obtain the patient's vital signs. b. Place a cervical collar on the patient. c. Assess for the contact points. d. Place on a cardiac monitor.

Correct Answer: B Rationale: Cervical spine injuries are commonly 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 spinal cord injury.

When assessing an emergency department patient who spilled hot oil from a deep-fat fryer on the right leg and foot, the nurse notes that the leg and foot are red, swollen, and covered with large blisters. The patient states that they are very painful. The nurse will document the injury as a. full-thickness skin destruction. b. deep partial-thickness skin destruction. c. superficial partial-thickness skin destruction. d. deep full-thickness skin destruction.

Correct Answer: B Rationale: The erythema, swelling, and blisters point to a deep partial-thickness burn. With full-thickness skin destruction, the appearance is pale and dry or leathery and the area is painless because of the associated nerve destruction. With superficial partial thickness burns, the area is red, but no blisters are present.

A patient with deep partial-thickness and full-thickness burns of the face and chest has the wounds treated with the open method. The nurse identifies an expected patient outcome of absence of wound infections. An appropriate nursing action to help the patient meet the outcome is to a. restrict all visitors prevent cross-contamination of wounds. b. wear gowns, caps, masks, and gloves during all care of the patient. c. use sterile water for cleansing and debridement in the hydrotherapy tank. d. administer prophylactic antibiotics to prevent bacterial colonization of wounds.

Correct Answer: B Rationale: 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. Restricting visitors is not necessary and will have adverse psychosocial consequences for the patient. Tap water is used during hydrotherapy, and hydrotherapy tanks are not usually used in burn care because of the risk of cross-contamination. Systemic antibiotics are not well absorbed into deep burns because of the lack of circulation.

A patient who has burns on the back and legs from a house fire has become agitated and restless 9 hours after being admitted to the hospital. Which action should the nurse take first? a. Administer the ordered morphine sulfate IV. b. Assess orientation and level of consciousness. c. Use pulse oximetry to check the oxygen saturation. d. Stay at the bedside and reassure the patient.

Correct Answer: C Rationale: Agitation in a patient who may have suffered inhalation injury might indicate hypoxemia, 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 loss 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.

A patient is admitted to the emergency department after suffering an electrical burn from exposure to a high-voltage current. In addition to the burn injuries, the most essential assessment is a. blood urea nitrogen (BUN) and creatinine levels. b. pupils' reaction to light. c. extremity movement. d. peripheral pulses.

Correct Answer: C Rationale: 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 cervical spine status

A patient with burns has the nursing diagnosis of pain related to lack of knowledge of pain-control methods. The most appropriate nursing action for this nursing diagnosis is to a. request that the health care provider order a patient-controlled analgesia machine for the patient. b. administer pain medications on a routine basis so that pain does not become out of control. c. teach the patient how to use ordered analgesics with adjunctive methods such as guided imagery and relaxation. d. use sedative or amnesic drugs in combination with opioids to reduce the perception of the pain experience.

Correct Answer: C Rationale: Since the etiology of the pain is the patient's lack of knowledge about pain control, teaching the patient about how to use adjunctive methods is an appropriate intervention. The other nursing actions may also be used to reduce pain but do not require any behavior change by the patient.

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 56%, Hb 17.2 mg/dl (172 g/L), serum K+ 4.8 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Based on these findings, the nurse should plan to a. document the findings in the patient's record. b. continue to monitor the laboratory results. c. increase the rate of the ordered IV solution. d. type and crossmatch for a blood transfusion.

Correct Answer: C Rationale: The patient's lab data show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Documentation and continuing to monitor are inadequate responses to the data. Since the hematocrit and hemoglobin are elevated, a transfusion is inappropriate.

Six hours after a thermal burn injury involving the anterior and posterior chest and both arms, the nurse obtains all of these data when assessing a patient. Which information is most important to communicate to the health care provider? a. Blood pressure is 94/46 per arterial line. b. Cardiac monitor shows a pulse rate of 104. c. Urine output is 20 to 30 ml per hour. d. Serous exudate is leaking from the burns.

Correct Answer: C Rationale: The urine output should be at least 30 to 50 ml/hour 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 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.

The nurse caring for a patient admitted with burns over 30% of the body surface will recognize that the patient has moved from the emergent to the acute phase of the burn injury when a. the patient has been hospitalized for 48 hours. b. blisters and edema have subsided. c. white blood cell levels decrease. d. the patient has large quantities of pale urine.

Correct Answer: D Rationale: 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 patient's immune status and any infectious processes

To provide wound care for the patient with deep partial-thickness and full-thickness burns, the nurse plans to a. apply sterile wet-to-dry dressings to burned areas bid. b. clean and scrub the wounds twice a week to remove eschar. c. immerse the patient in a hydrotherapy tank for 30 minutes 4 times daily. d. shower or bathe the patient daily to remove loose, necrotic skin.

Correct Answer: D Rationale: Daily showers or baths are commonly used for wound debridement. Wet-to-dry dressings are not usually used because the dressings will pull away new dermis and epidermis. Although some dressings can remain in place for 3 days, the wounds are gently cleaned, not scrubbed. Hydrotherapy can lead to sodium loss and decreased body temperature and is not ordered 4 times daily.

The nurse admitting a patient with an extensive burn injury develops a nursing diagnosis of risk for imbalanced nutrition: less than body requirements related to high caloric needs. The initial action by the nurse should be to a. encourage an oral intake of at least 5000 kcal per day. b. administer multiple vitamins and minerals in the IV solution. c. infuse total parenteral nutrition via a central catheter. d. insert a feeding tube and give 20 ml/hr enteral feedings.

Correct Answer: D Rationale: 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 patient's caloric needs. Parenteral nutrition increases the infection risk, does not help preserve gastrointestinal function, and is not routinely used in burn patients.

When positioning a patient with burns of the head, neck, chest, and right arm and hand, the nurse places the patient a. laterally with a small pillow under the head and the right arm and hand hyperextended. b. supine with no pillow and the right arm and hand flexed in a position of comfort and elevated. c. supine with a small pillow under the head and the right arm and hand elevated on a pillow. d. in a Fowler's position without a pillow with the right arm and hand extended and elevated on a pillow.

Correct Answer: D Rationale: The patient should be placed in Fowler's position to make ventilation easier. Pillows should not be used under the head of a patient with neck burns, and the arms and hands should be extended to avoid flexure contractures, even though this position will not be as comfortable for the patient.

The RN observes all of these actions being taken by a staff nurse who has floated to the unit. Which action requires that the RN intervene? a. The float nurse obtains burn cultures when the patient has a temperature of 95.2° F. b. The float nurse calls the health care provider for an insulin order when a nondiabetic patient has an elevated serum glucose. c. The float nurse administers as-needed fentanyl (Sublimaze) IV to a patient 5 minutes before a dressing change. d. The float nurse lowers room temperature to 76° F during the dressing change of a patient with large burns.

Correct Answer: D Rationale: The patient with large burns requires a room temperature of 85° F degrees during dressing changes to avoid becoming hypothermic. Hypothermia is an indicator of possible sepsis, and cultures are appropriate. Nondiabetic patients may require insulin because stress and high calorie intake may lead to temporary hyperglycemia. Fentanyl peaks 5 minutes after IV administration and should be used just before and during dressing changes for pain management.

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

Correct answer: c Rationale: Recovery from a burn injury to 30% of total body surface area (TBSA) 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. The patient would benefit from the nurse's careful review of his or her progress and readiness for discharge; then the nurse should outline the plans for support and follow-up after discharge.

A patient is admitted to the burn center with burns of his head and neck, chest, and back after an explosion in his garage. On assessment, the nurse auscultates wheezes throughout the lung fields. On reassessment, the wheezes are gone and the breath sounds are greatly diminished. Which action is the most appropriate for the nurse to take next? a. obtain vital signs and a STAT ABG b. encourage the patient to cough and auscultate the lungs again c. document the findings and continue to monitor the patient's breathing d. anticipate the need for endotracheal intubation and notify the physician

Correct answer: d Rationale: Inhalation injury results in 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 intubation and mechanical ventilation because this patient is demonstrating signs of severe respiratory distress.

After starting fluid replacement via a central subclavian catheter, the physician intubates pt. with an orotracheal endotube. She is transferred to the burn unit where an arterial line and small bore nasogastric tube are placed. Her facial burns will be treated with the open method while the rest of her burns will be treated with impregnated sterile gauze dressings. Select all the appropriate interventions you would plan for pt during this emergent phase of her burns. There are 10 correct answers. 1. Elevate her arms on pillows in a flexed position. 2. Assess her blood pressure with a thigh cuff q1hr. 3. Monitor her weight daily. 4. Initiate active and passive range-of-motion (ROM) exercises to her arms and neck. 5. Place pillows under her head for comfort. 6. Establish a method of communication for P.B. to express her needs. 7. Use sterile gloves to apply topical antimicrobial agents to the wounds. 8. Administer high-caloric, high-protein enteral tube feedings. 9. Administer IV pain medication 1 to 2 hours before wound care. 10. Monitor her urinary output each shift. 11. Keep the room at 85° F (29.4° C). 12. Instill artificial tears as needed. 13. Wear disposable cap, mask, gown, and gloves when providing direct patient care. 14. Monitor mental status and pulmonary function every 1 to 2 hours. 15. Apply sequential compression devices to lower extremities.

Correct answers: 3,4,6,7,8,11,12,13,14,15 Incorrect rationales: 1. risk of contractures. 2. BP frequency incorrect 5. This places airway at risk 9. IVP pain meds: onset is much faster than 1-2h 10. Frequency incorrect

Pain management for the burn patient is most effective when (SATA): a. a pain rating tool is used to monitor the patient's level of pain b. painful dressing changes are delayed until the patient's pain is completely relieved c. the patient is informed about and has some control over the management of the pain d. a multi-modal approach is used (e.g., sustained-release and short-acting opioids, NSAIDS, adjuvant analgesics). e. non-pharmacological therapies (e.g., music therapy, distraction) replace opioids in the rehabilitation phase of a burn injury

Correct answers: a, c, d Rationale: 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. A selected variety of medications offer better pain relief for patients with burns, whose pain can be both continuous and treatment related over varying periods of time. It is not realistic to promise a patient that pain will be completely eliminated. It is not realistic to suggest that pain will be managed (during any phase of burn care) with nonpharmacologic pain management. Such management is meant to be adjuvant and individualized.

A client with partial-thickness wounds of the face and chest caused by a campfire is admitted to the burn unit. The nurse plans to carry out which physician request first? A) Give oxygen per non-rebreather mask at 100% FiO2 B) Infuse lactated Ringer's solution at 150mL/hr C) Give morphine sulfate 4 to 10mg IV for pain control D) Insert a 14 Fr retention catheter

Correct: A Facial burns are frequently associated with upper airway inflammation. Administration of oxygen will assist in maintaining the client's tissue oxygenation at an optimal level.

When teaching fire safety to parents at a school function, the school nurse offers advice about the placement of smoke and carbon monoxide detectors with which statement? A) ''Every bedroom should have a separate smoke detector.'' B) ''Every room in the house should have a smoke detector.'' C) ''If you have a smoke detector, you don't need a carbon monoxide detector.'' D) ''The kitchen and bedrooms are the only rooms that need smoke detectors.''

Correct: A The number of detectors needed depends on the size of the home. Recommendations are that each bedroom should have a separate smoke detector, at least one detector should be placed in the hallway of each floor of the house, and at least one detector is needed for the kitchen, stairway, and home entrance.

A client with a burn injury due to a house fire is admitted to the burn unit. The client's family asks the nurse why the client received a tetanus toxoid injection on admission. What is the nurse's best response to the client's family member? A) "The last tetanus injection was less than 5 years ago." B) "Burn wound conditions promote the growth of Clostridium tetani." C) "The wood in the fire had many nails, which penetrated the skin." D) "The injection was prescribed to prevent infection from Pseudomonas."

Correct: B Burn wound conditions promote the growth of Clostridium tetani, and all burn clients are at risk for this dangerous infection. Tetanus toxoid, 0.5 mL given IM, enhances acquired immunity to C. tetani. This agent is routinely given when the client is admitted to the hospital.

The client is in the emergent phase of burn injury. Which route does the nurse use to administer pain medication to the client? A) Intramuscular B) Intravenous C) Sublingual D) Topical

Correct: B During the resuscitation postburn phase, the IV route is used for giving opioid drugs because of problems with absorption from the muscle and stomach. When these agents are given by the intramuscular or subcutaneous route, they remain in the tissue spaces and do not relieve pain. In addition, when edema is present, all doses are rapidly absorbed at once when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics.

The nurse on a burn unit has just received change-of-shift report about these clients. Which client will the nurse assess first? A) Adult client admitted a week ago with deep partial-thickness burns over 35% of the body who is reporting pain B) Firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers, "I can't catch my breath!" C) An electrician who suffered external burn injuries a month ago and is asking the nurse to contact the health care provider immediately about discharge plans D) Older adult client admitted yesterday with partial and full thickness burns over 40% of the body who is receiving IV fluids at 250mL/Hr

Correct: B Smoke inhalation and facial burns are associated with airway inflammation and obstruction. The client with difficulty breathing needs immediate assessment and intervention

Correct: B The client who suffered burn injuries in a closed space is at greatest risk for inhalation injury because the client breathed a greater concentration of confined smoke.

The nurse is caring for the client with burns to the face. Which statement by the client requires further evaluation by the nurse? A) ''I am getting used to looking at myself.'' B) ''I don't know what I will do when people stare at me.'' C) ''I know that I will never look like I used to, even after the scars heal.'' D) ''My spouse does not stare at the scars as much as in the beginning.''

Correct: B This statement indicates that the client is not coping effectively; the nurse should assist the client in exploring coping techniques.

The nursing student is caring for the client with open wound burns. Which priority nursing interventions does the nursing student include for this client? (Select all that apply.) A) Provides cushions and rugs for comfort B) Cleans equipment daily C) Performs frequent handwashing D) Provides fresh fruits and vegetables E) Performs gloved dressing changes F) Provides plants and flowers in the room G) Uses disposable dishes

Correct: B,C,E,G B) Rationale: Daily cleaning of the equipment and general housekeeping are essential for infection control. C) Rationale: All isolation methods use proper and consistent handwashing as the most effective technique for preventing infection transmission. E) Rationale: Use of asepsis requires all health care personnel to wear gloves during all contact with open wounds. G) Rationale: Disposable items (e.g., pillows, syringes, and dishes) are used as much as possible.

The nurse is caring for a burn client who is receiving topical gentamicin sulfate (Garamycin). What laboratory value will the nurse plan to monitor? A) Blood glucose B) C-reactive protein C) Serum and urine creatinine D) Platelet count

Correct: C Topical gentamicin may have nephrotoxic effects, and the nurse should monitor serum and urine creatinine clearance before and during treatment.

When delegating care for clients on the burn unit, which client will the charge nurse assign to an RN who has floated to the burn unit from the pediatric unit? A) Burn unit client who is being discharged after 6 weeks and needs teaching about wound care B) Recently admitted client with a high-voltage electrical burn C) A client who has a 25% total body surface area burn injury for whom daily wound debridement has been prescribed D) Client receiving IV lactated Ringer's solution at 100mL/hr

Correct: D An RN float nurse will be familiar with administration of IV fluids and with signs of fluid overload, such as shortness of breath.

The client is a burn victim who is noted to have increasing edema and decreased urine output as a result of the inflammatory compensation response. What does the nurse do first? A) Administers a diuretic B) Provides a fluid bolus C) Recalculates fluid replacement based on time of hospital arrival D) Titrates fluid replacement

Correct: D The intravenous fluid rate should be adjusted on the basis of urine output plus serum electrolyte values (titration of fluids).

A patient has been treated for second- and third-degree burns over 30% of his body and is now ready for discharge. You provide discharge instructions related to wound care. Which statement indicates that the patient understands the instructions? A. "I can expect occasional periods of low-grade fever and can take Tylenol every 4 hours." B. "I must wear my Jobst elastic garment all day and can remove it only when I'm going to bed." C. "I will need to take sponge baths at home to avoid exposing the wounds to unsterile bath water." D. "If any healed areas break open, I should cover them with a sterile dressing and then immediately report it."

D. "If any healed areas break open, I should cover them with a sterile dressing and then immediately report it."

A patient is being treated for second and third-degree burns over 30% of his body and is now ready for discharge. The nurse provides discharge instructions related to wound care. What statement indicates that the patient understands the instruction? A. "i can expect occasional periods of low-grade fever and can take tylenol every 4 hours" B. "I must wear my Jobst elastic garment all day and can only remove it when I'm going to bed" C. "I will need to take sponge baths at home to avoid exposing the wounds to unsterile bath water" D. "if any healed areas break open I should cover then with a sterile dressing and immediately report it"

D. "if any healed areas break open I should cover then with a sterile dressing and immediately report it"

You are caring for a burn patient who is in the later stages of the acute phase of the burn injury. What is an important factor in your care of the patient? A) Immobilizing the patient B) Maintaining splints and functional devices C) Maintaining ongoing discussion about the patient with a psychologist D) Prevention of DVT

PREVENTION OF DVT **Prevention of deep vein thrombosis (DVT) is an important factor in care. Early mobilization of the patient is important. The nurse monitors the splints and functional devices, but does not maintain them. The nurse does not maintain discussion with a psychologist about the patient.

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)? a. escharotomy b. administration of diuretics c. IV and oral pain medications d. daily cleansing and debridement e. application of topical antimicrobial agent

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.

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 the anticipated therapeutic outcome of the escharotomy is: a. return of distal pulses b. brisk bleeding from the site c. decreasing edema formation d. formation of granulation tissue

a. Escharotomies arepreformed to relieve the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential third degree burn.

A client's burn is infected and mafenide (Sulfamylon) is prescribed. The nurse's knowledge about this medication would indicate that which organism is involved? a. pseudomonas aeruginosa b. tubercle bacillus c. Methicillin resistant staphylococcus aureus (MRSA) d. Candida albicans

a. Mafenide is useful in treatment of partial and full thickness burns to prevent septicemia caused by organisms suche as pseudomonas aeruginosa.

A male burn pt who was struck by lightning arrives at the emergency department with full thickness burns to the arms and chest and with a cervical collar in place. Which assessment finding is the nurse's priority? a. serum K+ of 5.6 mEq/L b. Arterial blood ph of 7.35 c. Cervical spine fracture d. hemoglobin 18g/dL

a. The pt's potassium level puts them at risk for life threatening cardiac dysrhythmias.

A therapeutic measure used to prevent hypertrophic scarring during the rehabilitative phase of burn recovery is: a. applying pressure garments. b. repositioning the pt every 2 hours c. performing active ROM at least every 4 hours d. massaging the new tissue with water based moisturizers

a. applying pressure garments. 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.

A patient with a burn inhalation injury is receiving albuterol (Ventolin) for bronchospasm. What is the most important adverse effect of this medication for the nurse to manage? a. GI distress b. tachycardia c. restlessness d. hypokalemia

b. Albuterol (Ventolin) stimulates β-adrenergic receptors in the lungs to cause bronchodilation. However, it is a non-cardioselective 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.

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? a. The total 24-hour fluid requirement should be administered in the first 8 hours. b. One half of the total 24-hour fluid requirement should be administered in the first 8 hours. c. One third of the total 24-hour fluid requirement should be administered in the first 4 hours. d. One half of the total 24-hour fluid requirement should be administered in the first 4 hours.

b. 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.

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? a. SQ tetanus toxoid b. IV morphine sulfate c. IM hydromorphone d. PO oxycodone and acetaminophen

b. IV medications are used for burn injuries in the emergent phase to rapidly deliver relief and prevent unpredictable absorption as would occur with the IM route. The PO route is not used because GI function is slowed or impaired due to 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.

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

b. The clinical appearance of superficial partial-thickness burns includes erythema, blanching with pressure, and pain and minimal swelling with no vesicles or blistering during the first 24 hours.

A patient is admitted with second- and third-degree burns covering the face, entire right upper extremity, and the right anterior trunk area. Using the rule of nines, what should the nurse calculate the extent of these burns as being? a. 18% b. 22.5% c. 27% d. 36%

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. Since 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 approximately 22.5% of the total body surface area.

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%. Based on this level, the nurse would anticipate which of the following signs in the client? a. coma b. flushing c. dizziness d. tachycardia

b. 11-20% - signs include flushing, headache, decreased visual acuity, decreased cerebral functioning, and slight breathlessness. 21-40% - signs include nausea, vomiting, dizziness, tinnitus, vertigo, confusion, drowsiness, pale to reddish-purple skin, tachycardia; levels of 41-60% result in seizure and come and levels higher than 60% result in death

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 of the following recommendations? A. The total 24-hour fluid requirement should be administered in the first 8 hours. B. One half of the total 24-hour fluid requirement should be administered in the first 8 hours. C. One third of the total 24-hour fluid requirement should be administered in the first 4 hours. D. One half of the total 24-hour fluid requirement should be administered in the first 4 hours.

To maintain a positive nitrogen balance in a major burn, the patient must a. increase normal caloric intake by about 3 times b. eat a high-protein, low-fat, high-carbohydrate diet. c. eat at least 1500 calories per day in small, frequent meals. d. eat rice and whole wheat for the chemical effect on nitrogen balance

b. eat a high-protein, low-fat, high-carbohydrate diet. 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 delayed healing.

When caring for a patient with an electrical burn injury, which order from the health care provider should the nurse question? a. mannitol 75 gm IV b. urine for myoglobulin c. LR at 25 mL/h d. sodium bicarbonate 24 mEq q.4h

c. An infusion rate of 25 mL/hr is not sufficient to maintain adequate urine output in prevention and treatment of ATN. 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 2-4 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.

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? a. sit or lay in the position of comfort b. wear a pressure garment for 8 hours each day c. refer the patient to a counselor for phychosocial support d. use the sun to increase the skin color on the healed areas

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 they 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.

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 her new home? a. cook for her b. stop her from smoking c. install tap water anti-scald devices d. be sure she uses and open space heater

c. 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.

The burn nurse is aware that wound care during the acute phase involves consideration of which of the following? a. First and superficial second-degree burns can usually be managed with clean technique. b. Deep second-degree burns with or without impaired circulation heal without surgical intervention. c. Full thickness burns require surgical intervention to heal. d. The presence of infection is a contraindication to surgical wound management.

c. Full thickness burns require surgical intervention to heal.

The adult client was burned as a result of an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's 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 be the extent of the burn injury? a. 18% b. 24% c. 36% d. 48%

c. anterior head = 4.5%, upper half of anterior torso = 9%, lower half of both arms is 9%, posterior head 4.5%, upper half of posterior torso 9%, total 36%

The nurse is caring for a client following an autograft and grafting to a burn would on the right knee. Which of the following would the nurse anticipate to be prescribed for the client? a. out of bed b. brp c. Immobilization of the affected leg d. placing the affected leg in a dependent position

c. autografts placed over joints or on the lower extremities after surgery often are elevated and immobilized for 3-7 days. this period allows the autograft time to adhere to the wound bed.

A patient is admitted to the burn center with burns over his head, neck, chest, back, and left arm and hand after an explosion and fire in his garage. On admission to the unit, you auscultate wheezes throughout the lung fields. On reassessment, you notice that the wheezes are gone and the breath sounds are greatly diminished. Which of the following actions is the most appropriate next step? a. place the pt in high fowler's position b. encourage the pt to cough and auscultate the lungs again c. document the results and continue to monitor the pt's progress d. anticipate the need for endotracheal intubation and notify the physician

d. Anticipate the need for endotracheal intubation, and notify the physician. Inhalation injury results in exposure of respiratory tract to intense heat or flames with inhalation of noxious chemicals, smoke, or carbon monoxide. You should anticipate the need for intubation.

A patient has been treated for second- and third-degree burns over 30% of his body and is now ready for discharge. You provide discharge instructions related to wound care. Which statement indicates that the patient understands the instructions? a. I can expect occasional periods of low grade fever and can take Tylenol every 4 hours b. I must wear my jobst elastic garment all day and can only remove it when I'm going to bed. c. I will need to take sponge baths at home to avoid exposing the wounds to unsterile bath water. d. If any healed areas break open, I should cover them with a sterile dressing and then immediately report it."

d. If any healed areas break open, I should cover them with a sterile dressing and then immediately report it."

An escharotomy must be performed in a client admitted for burns. Which statement accurately describes this procedure? 1 An incision is made through the burn eschar. 2 Anesthesia is administered to the client for pain. 3 Analgesia is not administered with this procedure. 4 The procedure is performed in the surgical suite

1. An incision is made through the burn eschar. Rationale: Escharotomy is a surgical procedure that is performed to treat inadequate tissue perfusion in the client with severe burns. In this procedure, an incision is made through the burn eschar. It helps to relive the pressure caused due to fluid accumulation near the chest and improves circulation. It is not necessary to administer anesthesia to the client as the nerve endings are destroyed due to the injury. The client is given sedation and analgesia to reduce anxiety. Although escharotomy is a surgical procedure, it is often performed in a treatment room.

The 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) A week

2 DAYS **Airway obstruction caused by upper airway edema can take as long as 48 hours to develop. Changes detected by x-ray and arterial blood gases may occur as the effects of resuscitative fluid and the chemical reaction of smoke ingredients with lung tissues become apparent.

How long must a client with burns wear pressure garments after undergoing biological dressing? 1 Once per week 2 24 hours per day 3 Daily for a month 4 Three hours per day

2. 24 hours per day Rationale: A client who has undergone biological dressing must wear pressure dressings to help heal grafts and prevent contractures and hypertrophic scars. The client is advised to wear them at least 23 hours per day, every day, until scar tissue is mature (12 to 24 months).

During the resuscitation postburn phase, which route is used to administer morphine for pain relief? 1 Intramuscular 2 Intravenous 3 Subcutaneous 4 Oral

2. Intravenous Rationale: IV opioid analgesics like morphine are administered for pain relief for maximum absorption and quick onset action of the drug. Due to severe muscle damage and damage to the dermis and epidermis layers, neither the intramuscular or subcutaneous routes of administration are viable. Drug absorption through the oral route is not efficient, and the onset of action is also very slow in oral medications.

In assessing a client in the rehabilitative phase of burn therapy, which priority problem does the nurse anticipate? 1 Intense pain 2 Potential for inadequate oxygenation 3 Reduced self-image 4 Potential for infection

3. Reduced self-image Rationale: In the rehabilitative phase of burn therapy, the client is discharged and his or her life is not the same. A priority problem of reduced self-image is expected. Intense pain and potential for inadequate oxygenation are relevant in the resuscitation phase of burn injury. Potential for infection is relevant in the acute phase of burn injury.

The nurse is caring for a burn client who is receiving topical gentamicin sulfate (Garamycin). What laboratory value does the nurse plan to monitor? 1 Blood glucose 2 C-reactive protein 3 Serum and urine creatinine 4 Platelet count

3. Serum and urine creatinine Rationale: Topical gentamicin may have nephrotoxic effects, and the nurse should monitor serum and urine creatinine clearance before and during treatment. Topical gentamicin sulfate does not affect blood sugar. C-reactive protein is used as a marker of inflammation. Topical gentamicin sulfate does not alter platelet counts.

A client is in the acute phase of burn injury. For which action does the nurse decide to coordinate with the registered dietitian? 1 Discouraging having food brought in from the client's favorite restaurant 2 Providing more palatable choices for the client 3 Helping the client lose weight 4 Planning additions to the standard nutritional pattern

4. Planning additions to the standard nutritional pattern Rationale: Nutritional requirements for the client with a large burn area can exceed 5000 kcal/day. In addition to a high calorie intake, the burn client requires a diet high in protein for wound healing. Consultation with the dietitian is required to help the client achieve the correct nutritional balance. It is fine for the client with a burn injury to have food brought in from the outside. The hospital kitchen can be consulted to see what other food options may be available to the client. It is not therapeutic for the client with burn injury to lose weight.

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 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 last half is given over 16 hours: 4 80 30 = 9600 mL total volume; 9600/2 = 4800 mL in the first 8 hours; 4800 mL/8 hr = 600 mL/hr.

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A, E, F

The patient arrives at the emergency department with full-thickness burns over the entire chest and back. What is the patient's priority need? A. Fluid resuscitation B. Intravenous (IV) antibiotics C. Tetanus immunization D. Intramuscular (IM) analgesic

A. Fluid resuscitation Rationale Fluid resuscitation is a priority in treating extensive full-thickness burns because of the risk of hypovolemic shock from fluids shifting out of blood vessels due to increased capillary permeability. This phase can begin as early as 20 minutes after the burn. Antibiotics and tetanus immunization are important, but fluid volume is a priority. Pain relief is not a priority because the nerve endings are destroyed, and IV analgesics should be given because absorption through the IM route is inadequate in the burned or edematous areas. Reference: 479

A. Painful red and white blisters Correct: Painful red and white blisters accompany a deep partial-thickness burn. Incorrect B. Painless, brownish-yellow eschar Incorrect: Painless, brownish-yellow eschar accompanies a full-thickness burn. C. Painful reddened blisters Incorrect: A painful reddened blister accompanies a superficial partial-thickness burn. D. Painless black skin with eschar Incorrect: Painless black skin with eschar accompanies a deep full-thickness burn.

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 patient's 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.

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C. encourage regular home fire exit drills

Fluid and electrolyte shifts that occur during the early emergent phase include A. adherence of albumin to vascular walls. B. movement of potassium into the vascular space. C. sequestering of sodium and water in the interstitial fluid. D. hemolysis of red blood cells from large volumes of rapidly administered fluid.

C. sequestering of sodium and water in the interstitial fluid. Rationale During the emergent phase, sodium rapidly shifts to the interstitial spaces and remains there until edema formation ceases. Reference: 479, 480

A nurse is caring for a patient during the acute phase of the burn. The nurse knows he is responsible for what? A) Restricting visitors to prevent infection B) Closely scrutinizing the burn wound to detect early signs of infection C) Cleaning the patient's room D) Maintaining the patient in a sterile environment

CLOSELY SCRUTINIZING THE BURN WOUND TO DETECT EARLY SIGNS OF INFECTION **The nurse is responsible for providing a clean and safe environment and for closely scrutinizing the burn wound to detect early signs of infection. Visitors are not restricted to a burn patient. The nurse does not clean the patient's room. The patient is maintained in a clean environment, not a sterile environment.

The 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) Daily for 2 to 3 months after the injury C) Continuously D) At night while sleeping for a year after the injury

CONTINUOUSLY Garments are worn continuously (ie, 23 hours a day).

An emergency department nurse has just received a burn victim brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the patient's body. The nurse knows that pathophysiologic changes resulting from major burns during the initial burn-shock period include what? A) Hyper-dynamic anabolism B) Hyper-metabolic catabolism C) Decreased cardiac output D) Organ hyper-function

DECREASED CARDIAC OUTPUT **Pathophysiologic changes resulting from major burns during the initial burn-shock period include tissue hypo-perfusion and organ hypo-function secondary to decreased cardiac output, followed by a hyper-dynamic and hyper-metabolic phase. Options A and B are distracters for this question.

What is a priority in the rehabilitation phase of the burn injury? A) Monitoring fluid and electrolyte imbalances B) Patient and family education C) Assessing wound healing D) Documenting family support

PATIENT AND FAMILY EDUCATION **Patient and family education is a priority in the acute and rehabilitation phases. There should be no fluid and electrolyte imbalances in the rehabilitation phase. Assessing wound healing is an ongoing function but it is not a priority in the rehabilitation phase. Documenting family support is not a priority in the rehabilitation phase.

Pt reports weight 120 lb with 36% TBSA. Using the Parkland Formula calculate the amount of fluid replacement for the next 24 hours.

Parkland Formula (weight in kg )x (4 ml LR) x (TBSA) = 24 hour fluid replacement guidelines 7853.76 ml over 24 hours

The nursing instructor is teaching about the emergent/resuscitative phase of burn injury. During this phase, what would the nursing instructor tell the students they should closely monitor in the laboratory values? A) Sodium deficit B) Bleeding time C) Potassium deficit D) Decreased hematocrit

SODIUM DEFICIT **Anticipated fluid and electrolyte changes that occur during the emergent/resuscitative phase of burn injury include potassium excess, sodium deficit, base-bicarbonate deficit, and elevated hematocrit.

It is time to change the dressings on a burn patient. What does the nurse do to reduce pain and discomfort at this time? A) The nurse lets the patient decide on when to change the dressing. B) The nurse skip's the dressing change if the patient is really uncomfortable. C) The nurse changes dressings as quickly as possible. D) The nurse lets the aide do the painful part of the dressing change.

THE NURSE CHANGES DRESSINGS AS QUICKLY AS POSSIBLE **The nurse works quickly to complete treatments and dressing changes to reduce pain and discomfort. Letting the patient decide the time of the dressing change lets the patient feel more in control. It doesn't reduce pain and discomfort. The nurse should never skip an ordered dressing change. You never delegate a dressing change on a burn patient.

When caring for a client with extensive burns, the nurse anticipates that pain medication will be administered via which route? a. oral b. IV c. IM d. Subq

The nurse is performing a primary burn assessment according to the ABCs (airway, breath, circulation) guidelines. Which of the following indicate signs and symptoms of inhalation injury? a.Facial swelling and bruising. b. Progressive stridor and hoarseness. c. Singed chest hairs. d. Increased body temperature.

b. Progressive stridor and hoarseness

What is the best method for preventing hypovolemic shock in a client admitted with severe burns? a. administering dopamine b. applying medical antishock trousers c. infusing i.v. fluids d. infusing fresh frozen plasma

c. during the early postburn period, large amounts of plasma fluid extravasates into interstitial spaces. Restoring the fluid loss is necessary to prevent hypovolemic shock; this is best accomplished with crystalloid and colloid solutions.

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

c. sequestering of sodium and water in the interstitial fluid.

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? a. full liquids only b. whatever the patient requests c. high-protein and low sodium foods d. high calorie and high protein foods

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.

The ambulance reports that they are transporting a patient to the ED who has experienced a full-thickness thermal burn from a grill. What manifestations should 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

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.

A male pt suffered full thickness burns to the chest and back and the nurse notes the pressure alarm on his mechanical ventilator is sounding every 5 minutes. What is the most relevant assessment to prevent respiratory complications in this pt? a. pH b. PaCO2 c. Breath sounds d. chest expansion

d. assessing the pt's chest expansion is initially the most important because a sever burn that includes the anterior and posterior thorax can restrict chest expansion from eschar or scar tissue.

Pt's endotracheal tube is removed as her edema subsides, but she is withdrawn and refuses to participate in self-care. She tells you that she would rather die than look like she does. An appropriate approach to use in helping P.B. with her grieving is to: 1. encourage her to talk about her fears regarding her disfigurement and loss of function. 2. assure her that as the wounds heal, she will have little or no scarring and deformity. 3. encourage her family to visit frequently and tell her that her appearance isn't important. 4. explain that if she doesn't perform the prescribed exercises and activities, contractures will develop that will limit her function even more.

1. encourage her to talk about her fears regarding her disfigurement and loss of function. Grieving related to a change in body image and loss of self-esteem are experienced by most patients with major burns. Encouraging them to work through the stages of grief at their own pace is important. Adjustment to an altered body image can be facilitated by encouraging them to express their feelings and promoting independence.

As fluid therapy is being initiated for pt you monitor her condition closely. You prioritize assessment for which complication during this period? 1. Infection 2. Contractures 3. Pulmonary edema 4. Compartment syndrome

3. Pulmonary edema Pt is at high risk for PE r/t the high IVF rate and hx of CHF. The others are also risks but not the most immediate concerns.

How does the nurse determine accurate calorie requirements for a client with burns? 1 Calculating the body mass index regularly 2 Measuring body weight regularly 3 Using indirect calorimetry 4 Using the Parkland formula

3. Using indirect calorimetry Rationale: Indirect calorimetry can be used to determine the accurate calorie requirements of a client with burns. This method determines energy expenditure by measuring oxygen consumption and carbon dioxide production. Differences in body mass index and body weight will not provide information about the exact caloric requirements of a client. They give an idea regarding the relative nutritional requirements of an individual. The Parkland formula is used to calculate the amount of fluid necessary for fluid resuscitation of clients with burns.

During the emergent phase when pt is intubated, she becomes very agitated and anxious, groping around with her arms. You may alleviate her distress by: 1. giving her a familiar object to hold. 2. administering her ordered analgesic. 3. providing her with a pen and paper to be able to write her needs. 4. explaining that she will be able to see when the edema decreases.

4. explaining that she will be able to see when the edema decreases. R: You were able to visualize this patient and realize that the periorbital edema of her facial burns will prevent her from opening her eyes. P.B. cannot talk because of the endotracheal tube, and when she cannot open her eyes, it can be very frightening.

A patient is admitted to the emergency department with first- and second-degree burns after being in a house fire. Which assessment findings alert you 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 lower extremities E. History of being in a large fire

A, C, E Rationale Reliable clues to the occurrence of inhalation injury are 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, and cherry red skin color. Reference: 474

SHORT ANSWER 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?

ANS: 600 mL 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 last half is given over 16 hours: 4 × 80 × 30 = 9600 mL total volume; 9600/2 = 4800 mL in the first 8 hours; 4800 mL/8 hr = 600 mL/hr.

A 94-year-old gentleman is admitted from home to the hospital with pneumonia. Which factors would lead the nurse to believe he is nearing the end of his life? A. His abdomen is distended and his skin tone is yellow B. He has a fever of 101.6° F (38.7° C) and a respiratory rate of 28 per minute C. He has been having difficulty swallowing and is losing weight D. He has crackles in his lung bases bilaterally

ANS: C

Which of the following nursing actions is best before administering pain medication for cancer pain? A. Assess the patient's anxiety level B. Assess the patient's understanding of the side effects of pain medication C. Determine the patient's pain tolerance D. Assess the success of past pain management measures

ANS: D

ANS: D H2 blockers and proton pump inhibitors are given to prevent Curling's ulcer in the patient who has suffered burn injuries. Proton pump inhibitors usually do not affect bowel sounds, stool frequency, or appetite. DIF: Cognitive Level: Apply (application) REF: 465 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

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? a. Insert two large-bore IV lines. b. Check the patient's 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 patient's 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. DIF: Cognitive Level: Apply (application) REF: 455 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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 nurse's immediate, priority concern when planning this patient's care? A) Fluid status B) Risk of infection C) Nutritional status D) Psychosocial coping

Ans: A Feedback: During the early phase of burn care, the nurse is most concerned with fluid resuscitation, to correct large-volume fluid loss through the damaged skin. Infection control and early nutritional support are important, but fluid resuscitation is an immediate priority. Coping is a higher priority later in the recovery period.

A patient in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the patient's 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

Ans: A Feedback: Fluid and electrolyte changes in the emergent/resuscitative phase of a burn injury include hyperkalemia related to the release of potassium into the extracellular fluid, hyponatremia from large amounts of sodium lost in trapped edema fluid, hemoconcentration that leads to an increased hematocrit, and loss of bicarbonate ions that results in metabolic acidosis.

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 patient's preinjury health status C) The patient's prognosis for recovery D) The circumstances of the accident

Ans: A Feedback: The following factors are considered in determining the depth of a burn: how the injury occurred, causative agent (such as flame or scalding liquid), temperature of the burning agent, duration of contact with the agent, and thickness of the skin. The patient's preinjury status, circumstances of the accident, and prognosis for recovery are important, but are not considered when determining the depth of the burn.

A patient with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the patient closely for what signs of the onset of burn shock? A) Confusion B) High fever C) Decreased blood pressure D) Sudden agitation

Ans: C Feedback: As fluid loss continues and vascular volume decreases, cardiac output continues to decrease and the blood pressure drops, marking the onset of burn shock. Shock and the accompanying hemodynamic changes are not normally accompanied by confusion, fever, or agitation.

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

Ans: D Feedback: Prevention of deep vein thrombosis (DVT) is an important factor in care. Early mobilization of the patient is important. The nurse monitors the splints and functional devices, but these are selected by occupational and physical therapists. The hemodynamic changes accompanying burns do not normally require the use of beta blockers.

A client weighing 76 kg is admitted at 0600 with a TBSA burn of 40%. Using the Parkland formula, the client's 24-hour intravenous fluid replacement should be: A. 6,080 mL B. 9,120 mL C. 12,160 mL D. 15,180 mL

C. 12,160 mL

A patient with extensive electrical burn injuries is admitted to the emergency department. Which of these health care provider orders should the nurse implement first? a. Place on cardiac monitor. b. Start 2 large bore IVs. c. Assess for pain at contact points. d. Apply dressings to burned areas.

Correct Answer: A Rationale: After an electrical burn, the patient is at risk for fatal dysrhythmias and should be placed on a cardiac monitor. The other actions should be accomplished in the following order: Start 2 IVs, assess for pain, and apply dressings.

The client is in the acute phase of burn injury. In which situation does the nurse decide to coordinate with the nutritionist? A) To discourage having food brought in from the client's favorite restaurant B) To provide more palatable choices for the client C) To help the client lose weight D) To plan additions to the standard nutritional pattern

Correct: D Nutritional requirements for the client with a large burn area can exceed 5000 kcal/day. In addition to a high calorie intake, the burn client requires a diet high in protein for wound healing. Consultation with the dietitian is required to help the client achieve the correct nutritional balance.

What is the nursing goal during the acute phase of a burn? A) To ultimately prevent or control infection in the burn population B) To prevent hypervolemia in the burn population C) To manage pain in a proactive way for the patient's comfort D) To provide emotional support as the changes in body image become internalized in the patient

TO ULTIMATELY PREVENT OR CONTROL INFECTION IN THE BURN POPULAITON **The nursing goal is to provide protection and safety in the patients' environment to ultimately prevent or control infection in the burn population. This makes options B, C, and D incorrect.

b. silver sulfadiazine is a metallic type of antiseptic that is widely used on burns. The silver in the solution is toxic to bacteria, and prevents them from reproducing.

The nurse should expect to apply which type of ordered antiseptic to a client with a burn wound, once the area has been cleansed with sterile saline? a. copper containing b. silver containing c. biguanide d. acetic acid

a, c,. 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, and cherry red skin color

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)? a. the exercises are the only way to prevent contractures b. active and passive ROM maintain function of body parts c. ROM will show the patient that movement is still possible d. movement facilitates mobilization of leaked exudates back into the vascular bed. e. active and passive ROM can only be done while the dressings are being changed

b, c 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 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 has already taken analgesics, ROM can and should be done throughout the day.

While monitoring a burn victim, which of the following is considered the 'gold standard' to evaluate burn resuscitation? a. A heart rate less than 120 beats per minute, a blood pressure that is normal to slightly hypertensive and clear lung sounds. b. An adult urine output that is approximately 0.5-1.0ml/kg/hour. c. A pulmonary capillary wedge pressure of less than 18 mm Hg. d. A urinary output has been adequate for 2 hours.

b. An adult urine output that is approximately 0.5-1.0ml/kg/hour

b. silver sulfadiazine is a metallic type of antiseptic that is widely used on burns. The silver in the solution is toxic to bacteria, and prevents them from reproducing.

b. the first priority is halting the severity of the burn, to limit the depth of the burn and quick action must be a priority.

Pain management for the burn patient is most effective when a. opoids are administered on a set schedule around the clock b. the patient has as much control over the management of the pain as possible. c. there is flexibility to administer opioids withing a dosage and frequency range d. painful dressing changes are delayed until the pt's pain is totally relieved.

b. the patient has as much control over the management of the pain as possible. The more control the patient has in managing the pain, the more successful the chosen strategies. Active patient participation has been found to be effective for some patients in anticipating and coping with treatment-induced pain.

A patient is to undergo skin grafting with the use of cultured epithelial autografts full-thickness burns. The nurse explains to the patient that this treatment involves a) Shaving a split-thickness layer of the patient's skin to cover the burn wound. b) Using epidermal growth factor to cultivate cadaver skin for temporary wound coverage. c) Growing small specimens of the patient's skin into sheets to use as permanent skin coverage. d) Exposing animal skin to growth factors to decrease antigenicity so it can be used for permanent wound coverage.

c Rationale: Cultured epithelial autograft (CEA) is a method of obtaining permanent skin from a person with limited available skin for harvesting. CEA is grown from biopsy specimens obtained from the patient's own unburned skin.

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 90/50, a pulse of 110, and urine output of 20 mL over the past hour. The nurse reports the findings to the physician and anticipates which of the following prescriptions? a. transfusing 1 unit of packed red blood cells b. administering a diuretic to increase urine output c. increasing the amount of IV lactated Ringers solution administered per hour d. changing the IV lactated Ringer's solution to one that contains dextrose in water.

c. fluid management during the first 24 hours following a burn injury generally includes the infusion of LR solution. Fluid resuscitation is determined by urine output and hourly urine output should be at least 30mL/hr. The client's urine output is indicative of insufficient fluid resuscitation, which places the client at risk for inadequate perfusion of the brain, heart, kidneys, and other body organs. Therefore, should expect ↑ of LR's.

When monitoring initial fluid replacement for the patient with 40% TBSA deep partial-thickness and full-thickness burns, which finding is of most concern to the nurse? a) Serum K+ of 4.5 mEq/L b) Urine output of 35 mL/hr c) Decreased bowel sounds d) Blood pressure of 86/72 mm Hg

d Rationale: Adequacy of fluid replacement is assessed by urine output and cardiac parameters. Urine output should be 0.5 to 1 mL/kg/hr. Mean arterial pressure should be >65 mm Hg, systolic BP >90 mm Hg, and heart rate <120 beats/min. A blood pressure of 86/72 indicates inadequate fluid replacement. However, the MAP is calculated at 77 mm Hg.

Because of the location of pt burns and the treatment required, she is taken to the operating room for surgical debridement of her wounds. The majority of her chest and arm burns are deep partial-thickness burns, and about 30% of the burns on her face and abdomen are full-thickness burns. The physician applies sheet autografts from her thighs to the areas of full-thickness burns. Which teaching statements would be appropriate for the nurse to tell pt? (Select all that apply.) 1. "The skin grafts will help limit scars from forming." 2. "I will be checking your grafts frequently to make sure there are clots present to prevent bleeding." 3. "The surgeon scraped all the dead tissue off the burned areas before applying the grafts." 4. "The new skin grafts will help control your pain."

1,3,4 are correct. R: Clots between the graft and the wound keep the graft from adhering to the wound. Skillful nursing care is required to identify and manage clots quickly for the best functional and esthetic outcomes.

A client with 32% total body surface area burns has a hematocrit of 54% 10 hours after the burn injury and 8 hours after fluid resuscitation was started. What is the nurse's best action? 1 Assess the client's blood pressure and urine output. 2 Notify the health care provider immediately. 3 Evaluate the client's electrocardiogram for dysrhythmias. 4 Increase the IV infusion rate

1. Assess the client's blood pressure and urine output. Rationale: The massive fluid shift causes hemoconcentration of the cells in the blood. The first action needed is to evaluate the adequacy of the fluid resuscitation by assessing the client's blood pressure and hourly urine output. If fluid resuscitation is adequate, no other action is needed. If blood pressure and urine output indicate fluid resuscitation at the current rate is not adequate, the health care provider should be called and resuscitation volumes may be increased.

Several clients have been brought to the emergency department (ED) after an office building fire. Which client is at greatest risk for inhalation injury? 1 Middle-aged adult who is frantically explaining to the nurse what happened 2 Young adult who suffered burn injuries in a closed space 3 Adult with burns to the extremities 4 Older adult with thick, tan-colored sputum

2. Young adult who suffered burn injuries in a closed space Rationale: The client who suffered burn injuries in a closed space is at greatest risk for inhalation injury because the client breathed a greater concentration of confined smoke. Clients who experienced a fire typically have some type of respiratory distress. However, the client talking without difficulty demonstrates that the client has minimal respiratory distress. Extensive burns to the hands and face, not the extremities, would be a greater risk. Sputum would be carbonaceous, not tan, if the client had suffered inhalation injury.

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

Ans: D Feedback: Systemic threats from a burn are the greatest threat to life. The ABCs of all trauma care apply during the early postburn period. While all options should be addressed, pain, fluid balance, and anxiety and fear do not take precedence over airway management.

Multiple patients arrive in the emergency department from a house fire. Which patient is a priority? A. Patient with erythremic, dry burns over the arms and a history of taking prednisone B. Patient with moist blisters over the chest and who reports pain as 10 C. Patient with dry, black skin on one hand and a history of diabetes mellitus D. Patient with multiple reddened skin areas on the chest and with high-pitched respiratory sounds

D. Patient with multiple reddened skin areas on the chest and with high-pitched respiratory sounds Rationale Airway injury is a priority, and stridor results from a narrowing of the airway caused by edema. A history of prednisone use or diabetes is a concern for long-term infection risk, but the airway is always first. Reference: 477, 481

The nurse is caring for a client who has a severe burn injury and is receiving fluid resuscitation. The nurse should assess which laboratory findings to determine the client's response to the therapy? Select all that apply. A Liver enzyme levels B Red blood cell count C White blood cell count D Serum creatinine levels E Blood urea nitrogen levels

D.Serum creatinine levels E. Blood urea nitrogen levels Rationale: Fluid shifts and fluid loss occur in clients with severe burns. Fluid resuscitation is implemented to maintain fluid balance in the client's body. Serum creatinine levels are measured to assess fluid balance in the body, whereas blood urea nitrogen levels give information about kidney function. Fluid resuscitation will not affect the liver enzyme levels, red blood cell count, or white blood cell count. Therefore, it is not necessary to monitor these laboratory values while evaluating the effects of fluid resuscitation.

The acute phase of the burn begins 48 to 72 hours after the burn. What begins at this time? A) Cardiac output decreases B) Renal failure begins C) Diuresis D) Fluid moves from intravascular compartment to interstitial spaces

DIURESIS **As capillaries regain integrity, 48 or more hours after the burn, fluid moves from the interstitial to the intravascular compartment and diuresis begins. Cardiac output should increase and renal output should increase.

A child was admitted to the ED with a thermal burn to the right arm and leg. Which assessment by the nurse requires immediate action? a. coughing and wheezing b. bright red skin with small blister on the burn sites c. thirst d. singed hair

a. coughing and wheezing may indicate that the child has inhaled smoke or toxic fumes. Maintaining airway patency is the highest nursing priority in this situation.

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 of the following symptoms? A. Blisters B. Reddening of the skin C. Destruction of all skin layers D. Damage to sebaceous glands

b. The clinical appearance of superficial partial-thickness burns includes erythema, blanching with pressure, and pain and minimal swelling with no vesicles or blistering during the first 24 hours.

During the rehabilitation phase, the physical healing focuses primarily on wound healing. The burn nurse includes which the following in patient education to assist the patient and family for their return to the community? a.The immune system heals along with the skin and future risk of infection stabilizes. b. The hypermetabolic state lasts from 9-12 months following burn injury and body weight requires carefully monitoring. c. Extensive burn injury decreases the risk for developing bone density changes. d. Thermoregulation disturbances may result in an inability to adjust to changes in environment temperatures.

b. The hypermetabolic state lasts from 9-12 months following burn injury and body weight requires carefully monitoring.

When evaluating the burn extremity for the development of compartment syndrome, which signs and symptoms would alert the nurse to the possibility this has developed?? a.The presence of burn eschar that covers the entire lateral surface of the extremity. b. There is evidence of tautness, decreased capillary refill, coolness and decreased pulses. c. The edema is the area is rapidly dissipating resulting in hypoperfusion to the extremity. d. There is increased discomfort in the affected area.

b. There is evidence of tautness, decreased capillary refill, coolness and decreased pulses.

Which of the following dysfunctions can the nurse anticipate in the burn patient with deep partial or full thickness injury? a. There is retention of the ability of the skin to regulate core temperature. b. There is increased risk of infection due to a loss of integrity of a primary barrier. c. There is a decreased sensitivity to ultraviolet radiation. d. There is maintenance of the ability to absorb Vitamin D.

b. There is increased risk of infection due to a loss of integrity of a primary barrier

A female pt in the acute phase of burn care has electrical burns on the left side of her body, type 2 diabetes mellitus, and a serum glucose of 485 mg/dL. What is the nurse's priority for preventing a life threatening complication of hyperglycemia for the burn patient? a. replace the blood lost b. maintain a neutral pH c. Maintain fluid balance d. Replace serum potassium

c. this pt is most likely experiencing hyperglycemic hyperosmolar nonketotic syndrome (HHNKS) which dehydrates a patient rapidly. This increases the pt's risk for hypovolemia and hypotension.

The nurse plans emergent care for four male pt's who have burns covering between 40-50% of the total body surface area. Rank these patients according to their risk for an inhalation injury beginning with the pt who has the highest risk. a. has posterior chemical burns from an exhibit at a parking lot b. has osteoporosis and electrical burns of the lower extremities c. has thermal burns of the right side and is a volunteer fireman d. has chronic bronchitis and thermal burns around the abdomen

d, c, a, b.

A client with partial-thickness burns of the face and chest caused by a campfire is admitted to the burn unit. The nurse plans to carry out which health care provider request first? 1 Give oxygen per nonrebreather mask at 100% Fio2. 2 Infuse lactated Ringer's solution at 150 mL/hr. 3 Give morphine sulfate 4-10 mg IV for pain control. 4 Insert a 14 Fr retention catheter.

1. Give oxygen per nonrebreather mask at 100% Fio2. Rationale: Facial burns are frequently associated with upper airway inflammation. Administration of oxygen will assist in maintaining the client's tissue oxygenation at an optimal level. Although fluid hydration and pain control are important, the nurse's first priority is the client's airway. Monitoring output is important, but the nurse's first priority is the client's airway.

Which electrolyte abnormality does the nurse anticipate during the resuscitation phase in a client with burn injury? 1 Hyperkalemia 2 Hypernatremia 3 Hypochloremia 4 Hypoglycemia

1. Hyperkalemia Rationale: Hyperkalemia may occur during the resuscitation phase of burn injury because of the tissue destruction, disruption of the sodium-potassium pump, and red blood cell hemolysis. Hyponatremia (not hypernatremia), hyperchloremia (not hypochloremia), and hyperglycemia (not hypoglycemia) may also occur.

The 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) Impaired nutrition: less than body requirements D) Acute pain

ACUTE PAIN **Pain is inevitable during recovery from any burn injury. Pain in the burn patient has been described as one of the most severe causes of acute pain. Management of the often-severe pain is one of the most difficult challenges facing the burn team. While the other nursing diagnoses listed are valid diagnoses, the presence of pain may contribute to these diagnoses and management of the patient's pain is priority as it may have a direct correlation to these nursing diagnoses.

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 each arm is 9%. DIF: Cognitive Level: Understand (comprehension) REF: 454 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

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. DIF: Cognitive Level: Analyze (analysis) REF: 15-16 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

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. DIF: Cognitive Level: Apply (application) REF: 467 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which patient should the nurse assess first? a. A patient with smoke inhalation who has wheezes and altered mental status b. A patient with full-thickness leg burns who has a dressing change scheduled c. A patient with abdominal burns who is complaining of level 8 (0 to 10 scale) pain d. A patient with 40% total body surface area (TBSA) burns who is receiving IV fluids at 500 mL/hour

ANS: A This patient has evidence of lower airway injury and hypoxemia and should be assessed immediately to determine the need for oxygen or intubation. The other patients should also be assessed as rapidly as possible, but they do not have evidence of life-threatening complications. DIF: Cognitive Level: Apply (application) REF: 452 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

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

ANS: B Cervical spine injuries are commonly 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 spinal cord injury. DIF: Cognitive Level: Apply (application) REF: 452 | 456 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A client who was burned has crackles in both lung bases and a respiratory rate of 40 breaths/min and is coughing up blood-tinged sputum. Which action by the nurse takes priority? a. Administer digoxin. b. Perform chest physiotherapy. c. Document and reassess in an hour. d. Place the client in an upright position.

ANS: D Pulmonary edema can result from fluid resuscitation given for burn treatment. This can occur even in a young healthy person. Placing the client in an upright position can relieve lung congestion immediately before other measures can be carried out. Digoxin may be given later to enhance cardiac contractility to prevent backup of fluid into the lungs. Chest physiotherapy will not get rid of fluid.

While the patient's full-thickness burn wounds to the face are exposed, what is the best nursing action to prevent cross contamination? 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. DIF: Cognitive Level: Apply (application) REF: 461 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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. DIF: Cognitive Level: Apply (application) REF: 467 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

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. DIF: Cognitive Level: Apply (application) REF: 460 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A client who is burned is drooling and is having difficulty swallowing. Which action does the nurse take first? a. Assess level of consciousness and pupillary reactions. b. Ascertain the time food or liquid was last consumed. c. Auscultate breath sounds over the trachea and mainstem bronchi. d. Measure abdominal girth and auscultate bowel sounds.

ANS: C Inhalation injuries are present in 7% of clients admitted to burn centers. Drooling and difficulty swallowing can mean that the client is about to lose his airway because of this injury. Absence of breath sounds over the trachea and mainstem bronchi indicates impending airway obstruction and demands immediate intubation. Knowing the level of consciousness is important in assessing oxygenation to the brain. Ascertaining the time of last food intake is important, in case intubation is necessary (the nurse will be more alert for signs of aspiration). However, assessing for air exchange is the most important intervention at this time. Measuring abdominal girth is not relevant in this situation.

The spouse of a dying client states that she is concerned that her husband is choking to death. What is the nurse's best response? a. "Do not worry. The choking sound is normal during the dying process." b. "I will administer more morphine to keep your husband comfortable." c. "I can ask the respiratory therapist to suction secretions out through his nose." d. "I will have another nurse assist me to turn your husband on his side."

ANS: D The choking sound or "death rattle" is common in dying clients. The nurse should acknowledge the spouse's concerns and provide interventions that will reduce the choking sounds. Repositioning the client onto one side with a towel under the mouth to collect secretions is the best intervention. Morphine will assist with comfort (and dypsnea) but will not decrease the choking sounds. Nasal tracheal suctioning is not appropriate in a dying client. The nurse should not minimize the spouse's concerns.

A patient has 25% TBSA burned from a car fire. His wounds have been debrided and covered with a silver-impregnated dressing. The nurse's priority intervention for wound care would be to: A. reapply a new dressing without disturbing the wound bed B. observe the wound for signs of infection during dressing changes C. apply cool compresses for pain relief in between dressing changes D. wash the wound aggressively with soap and water three times a day

B. the patient has as much control over the management of the pain as possible

A burn victim is admitted to the Intensive Care Unit to stabilize and begin fluid resuscitation before transport to the burn center. If inadequate fluid resuscitation occurs what happens to the patient? A) Becomes unresponsive B) Distributive shock C) Death D) Hypovolemic shock

DISTRIBUTIVE SHOCK Prompt fluid resuscitation maintains the blood pressure in the low-normal range and improves cardiac output. Despite adequate fluid resuscitation, cardiac filling pressures (central venous pressure, pulmonary artery pressure, and pulmonary artery wedge pressure) remain low during the burn-shock period. If inadequate fluid resuscitation occurs, distributive shock occurs

A triage nurse in the ED admits a 50 year old male client with second degree burns on the anterior and posterior portions of both legs. Based on the Rule of Nines, what percentage of his body is burned? Record your answer using a whole number.

The anterior and posterior portions of one leg are 18%, if both legs are burned, the total is 36%.

Using the rule of nines calculate the TBSA of pt burns: face, neck, anterior trunk, full right arm, anterior left arm.

36 % face/anterior neck: 4.5 anterior trunk: 18 full right arm: 9 anterior left arm: 4.5

Where do most burn injuries occur? A) On the road B) At home C) At work D) Recreational accidents

AT HOME ** Of those people admitted to burn centers, 47% are injured at home, 27% on the road, 8% are occupational, 5% are recreational, and the remaining 13% are from other sources.

A Jewish client requires grafting to promote burn healing. Which graft is most likely to be unacceptable to the client? A. Isograft B. Autograft C. Homograft D. Xenograft

D. Xenograft

Which assessment does the nurse prioritize for the client in the acute phase of burn injury? A) Bowel sounds B) Muscle strength C) Signs of infection D) Urine output

Correct: C The client with burn injury is at risk for infection as a result of open wounds and reduced immune function. Burn wound sepsis is a serious complication of burn injury, and infection is the leading cause of death during the acute phase of recovery.

The nurse has just completed the dressing change for a client with burns to the lower legs and ankles. The nurse should place the client's ankles in which position? A. Internal rotation B. Abduction C. Dorsiflexion D. Hyperextension

C. Dorsiflexion

An African American client is admitted with full thickness burns over 40% of his body. In addition to the CBC and complete metabolic panel, the physician is likely to request which additional blood-work? A. Erythrocyte sedimentation rate B. Indirect Coombs C. C reactive protein D. Sickledex

D. Sickledex

A male patient, 16 years old, comes to the emergency department (ED) after burning his right hand and arm while working on a friend's car. The injury is determined to be a superficial burn and it is treated. What would the nurse teach the patient before discharging him home to return on a daily basis for dressing changes? A) "As your arm swells, push on your fingernails. If it takes longer than 5 seconds for them to get pink come back to the ED." B) "You should be fine until you come back tomorrow for your dressing change." C) "Drink lots of fluids and elevate the arm." D) "The burned area will start to swell in about 4 hours and blisters will form. If you think the dressing is too tight come back to the ED."

"The burned area will start to swell in about 4 hours and blisters will form. If you think the dressing is too tight come back to the ED." **In a superficial burn there is loss of capillary integrity and fluid is localized to the burn itself, resulting in blister formation and edema only in the area of injury. Capillary refill should be 3 seconds or less. Options B and C are distracters for this question.

Burn victim 64 Female, burns r/t gas explosion. Red, fluid filled vesicles and white waxy skin covering face, anterior neck, total right arm, dorsal left arm and anterior trunk. AAO x2, doesn't recall accident, anxious. Pt c/o severe facial and anterior chest pain. VS: 132 bpm, R 36, BP (thigh) 110/52. Hx: MI with CHF. Rx quinapril, furosemide, pravastatin. Priority actions (list correct order): a. Admin IV morphine b. Admin IV fluids c. Admin 100% humidified O2 d. Admin tetanus prophylaxis e. Establish IV access f. Initiate appropriate wound care g. Insert Foley cath h. Prep for nasotracheal or endotracheal intubation i. estimate body surface area burned.

(c, h, e, i, b, a, g, f, d) Admin 100% humidified O2 Prep for intubation IV access Estimate BSA burned IV fluids IV morphine Foley cath Initiate appropriate wound care Admin tetanus prophylaxis

A client with peripheral neuropathy is being discharged home after a pacemaker placement. What is the priority question to ask the client in assessing safety for home discharge planning to prevent burn-related injuries? 1 "Do you know how to ensure the hot water tank is set below 140° F?" 2 "Can friends provide meals for you for a few days?" 3 "Tell me how you test bath water before getting into the tub." 4 "Do you usually wear sunscreen when you are outside?"

1. "Do you know how to ensure the hot water tank is set below 140° F?" Rationale: The prevention of burns begins with planning and awareness. People should ensure hot water tanks are set below 140° F, especially for a client with peripheral neuropathy, as reduced sensation in the lower extremities may further reduce the client's ability to sense hot water effectively. Reeducating all clients on how to test water temperature before taking a bath/shower is also an important burn prevention assessment question, as is assessing the client's use of sunscreen.

The nurse is evaluating the effectiveness of fluid resuscitation for the client in the emergent phase of burn injury. Which finding does the nurse correlate with clinical improvement? A) Blood urea nitrogen (BUN), 36 mg/dL B) Creatinine, 2.8 mg/dL C) Urine output, 40 mL/hr D) Urine specific gravity, 1.042

Correct: C Fluid resuscitation is provided at the rate needed to maintain urine output at 30 to 50 mL or 0.5 mL/kg/hr.

Pt rapidly develops edema in burned and nonburned areas. You realize that her edema: 1. results from a hypervolemia that occurs with fluid replacement therapy. 2. May lead to hypovolemic shock as a result of intravascular volume depletion 3. is an indication of renal ischemia and acute tubular necrosis caused by sludging 4. is caused by decreased hydrostatic pressure resulting in fluid retention in the vasculature.

2. may lead to hypovolemic shock as a result of intravascular volume depletion. The increased capillary permeability that occurs with burns allows the movement of sodium, water, and plasma proteins into the interstitial spaces, resulting in an intravascular depletion and manifestations of hypovolemic shock. The hypovolemic shock is the greatest initial threat to a major burn victim.

The emergency department nurse has just admitted a patient with a burn. The nurse recognizes that the patient is likely to experience a local and systemic response to the burn when the burn exceeds a total body surface area (TBSA) of what? A) 10% B) 15% C) 20% D) 25%

25% **If the burn exceeds 20% to 25% TBSA, a nasogastric tube is inserted and connected to low intermittent suction. Often, patients with large burns become nauseated as a result of the gastrointestinal effects of the burn injury, such as paralytic ileus, and the effects of medication such as opioids. All patients who are intubated should have a nasogastric tube inserted to decompress the stomach and prevent vomiting.

The nurse is caring for a client with burns. Which question does the nurse ask the client and family to assess their coping strategies? 1 "Do you support each other?" 2 "How do you plan to manage this situation?" 3 "How have you handled similar situations before?" 4 "Would you like to see a counselor?"

3. "How have you handled similar situations before?" Rationale: Asking how the client and family have handled similar situations in the past assesses whether the client's and the family's coping strategies may be effective. Yes or no questions such as "Do you support each other?" are not very effective in extrapolating helpful information. The client and family in this situation probably are overwhelmed and may not know how they will manage; asking them how they plan to manage the situation does not assess coping strategies. Asking the client and the family if they would like to see a counselor also does not assess their coping strategies.

The nurse is evaluating the effectiveness of fluid resuscitation for a client in the resuscitation phase of burn injury. Which finding does the nurse correlate with clinical improvement? 1 Blood urea nitrogen (BUN), 36 mg/dL 2 Creatinine, 2.8 mg/dL 3 Urine output, 40 mL/hr 4 Urine specific gravity, 1.042

3. Urine output, 40 mL/hr Rationale: Fluid resuscitation is provided at the rate needed to maintain urine output at 30-50 mL or 0.5 mL/kg/hr. A BUN of 36 mg/dL is above normal, a creatinine of 2.8 mg/dL is above normal, and a urine specific gravity of 1.042 is above normal.

Twenty-four hours after admission to the burn unit, eschar begins to develop over her burned areas. You monitor the radial pulse in her right arm, recognizing that an escharotomy may be indicated to prevent: 1. contractures 2. excessive edema 3. ischemia and necrosis 4. infection

3. ischemia and necrosis

36 The anterior and posterior portions of one leg are 18%, if both legs are burned, the total is 36%.

A 45-year-old man is brought in by Life-Flight after a motor vehicle accident is which he was trapped in a burning vehicle. The burn team is estimating the patient's likelihood of survival based on the severity of the burn injury. The emergency department nurse knows that the severity of the injury is based on what factors? (Mark all that apply.) A) Age B) Depth of the burn C) Presence of inhalation injury D) Family support E) Psychological state of the patient

A, B, C AGE, DEPTH OF THE BURN, PRESENCE OF INHALATION INJURY **The severity of each burn injury is determined by multiple factors that when assessed help the burn team estimate the likelihood that a patient will survive and plan the care for each patient. These factors include age of the patient; depth of the burn; amount of surface area of the body that is burned; presence of inhalation injury; presence of other injuries; location of the injury in special care areas such as the face, perineum, hands, and feet; and presence of a past medical history. Options D and E are not factors that bear on the severity of the injury.

A. Encouraging participation in wound care Correct: Encouraging participation in wound care will offer the client some sense of control.

You are planning care for a patient with partial- and full-thickness skin destruction caused by a burn injury of the lower extremities. Which interventions will be included 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

A. Escharotomy C. IV and oral pain medications D. Daily cleansing and debridement E. Application of topical antimicrobial agent Rationale An escharotomy (scalpel incision through full-thickness eschar) is frequently required to restore circulation to compromised extremities. Daily cleansing and debridement and the application of an antimicrobial ointment are expected interventions used to minimize infection and enhance wound healing. With full-thickness burns, myoglobin and hemoglobin released into the bloodstream can occlude renal tubules. Adequate fluid replacement is used to prevent this occlusion. Pain control is essential in the care of a patient with a burn injury. Reference: 480, 483

A patient has just died, and his family is waiting to see him. What postmortem care is essential first? A. Document the time and circumstances of the death B. Place identification on the body according to hospital policy C. Clean the patient up and make him look peaceful D. Cover the patient's body and face with a sheet

ANS: C

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

B. One half of the total 24-hour fluid requirement should be administered in the first 8 hours. Rationale 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 fourth of total fluid requirement should be administered in the second 8 hours, and one fourth of total fluid requirement should be administered in the third 8 hours. Reference: 483

Pain management for the burn patient is most effective when A. opioids are administered on a set schedule around the clock. B. the patient has as much control over the management of the pain as possible. C. there is flexibility to administer opioids within a dosage and frequency range. D. painful dressing changes are delayed until the patient's pain is totally relieved.

B. the patient has as much control over the management of the pain as possible. Rationale The more control the patient has in managing the pain, the more successful the chosen strategies. Active patient participation has been found to be effective for some patients in anticipating and coping with treatment-induced pain. Reference: 490

As the patient begins the acute phase of a burn, cautious administration of fluids and electrolytes continues. The nurse knows that this caution is because of what? (Mark all that apply.) A) Patient is considered in critical condition B) Cardiac function is decreased C) Patient's physiologic responses to the burn injury D) Losses of fluid from large burn wounds E) Shifts in fluid from the interstitial to the intravascular compartment

C) Patient's physiologic responses to the burn injury D) Losses of fluid from large burn wounds E) Shifts in fluid from the interstitial to the intravascular compartment **Cautious administration of fluids and electrolytes continues during this phase of burn care because of the shifts in fluid from the interstitial to the intravascular compartment, losses of fluid from large burn wounds, and the patient's physiologic responses to the burn injury.

Knowing the most common causes of household fires, which prevention strategy do you focus on when teaching about fire safety? A. Set hot water temperature at 140° F (60° C). B. Use only hard-wired smoke detectors. C. Encourage regular home fire exit drills. D. Never permit older adults to cook unattended.

C. Encourage regular home fire exit drills. Rationale A risk-reduction strategy for household fires is to encourage regular home fire exit drills. 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). 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 while cooking is necessary only if they are cognitively impaired. Reference: 473

D. Airway injury is a priority, and stridor results from a narrowing of the airway caused by edema. A history of prednisone use or diabetes is a concern for long-term infection risk, but the airway is always first.

A patient is admitted to the burn center with burns over his head, neck, chest, back, and left arm and hand after an explosion and fire in his garage. On admission to the unit, you auscultate wheezes throughout the lung fields. On reassessment, you notice that the wheezes are gone and the breath sounds are greatly diminished. Which of the following actions is the most appropriate next step? A. Place the patient in a high-Fowler position. B. Encourage the patient to cough, and auscultate the lungs again. C. Document the results, and continue to monitor the patient's progress. D. Anticipate the need for endotracheal intubation, and notify the physician.

D. Anticipate the need for endotracheal intubation, and notify the physician. Rationale Inhalation injury results in exposure of respiratory tract to intense heat or flames with inhalation of noxious chemicals, smoke, or carbon monoxide. You should anticipate the need for intubation. Reference: 473

You are caring for a patient with partial- and full-thickness burns to 65% of the body. When planning nutritional interventions for this patient, you should implement which dietary choice? A. Full liquids only B. Whatever the patient requests C. High-protein and low-sodium foods D. High-calorie and high-protein foods

D. High-calorie and high-protein foods Rationale The patient's hypermetabolic state is proportional to the size of the burn area. Massive catabolism can occur. It is characterized by protein breakdown, and it increases gluconeogenesis. Caloric needs are often in the 5000-kcal range. Failure to supply adequate calories and protein leads to malnutrition and delayed healing. Reference: 486

A burn patient is brought to the emergency department. The nurse knows that the first systemic event after a major burn injury is what? A) Hemodynamic instability B) Metabolic acidosis C) Hypovolemia D) Hyperkalcemia

HEMODYNAMIC INSTABILITY **The initial systemic event after a major burn injury is hemodynamic instability, which results from loss of capillary integrity and a subsequent shift of fluid, sodium, and protein from the intravascular space into the interstitial spaces. Options B, C, and D occur, they are just not the first event to happen.

D. Titrate fluid replacement. Correct: The intravenous fluid rate should be adjusted on the basis of urine output plus serum electrolyte values (titration of fluids). Incorrect: A. Administer a diuretic. Incorrect: A common mistake in treatment is giving diuretics to increase urine output. Diuretics do not increase cardiac output. They actually decrease circulating volume and cardiac output by pulling fluid from the circulating blood volume to enhance diuresis. B. Provide a fluid bolus. Incorrect: Fluid boluses are avoided because they increase capillary pressure and worsen edema. C. Recalculate fluid replacement based on time of hospital arrival. Incorrect: Fluid replacement formulas are calculated from the time of injury, not from the time of arrival at the hospital.

A nurse on the burn unit is caring for a patient who has gone into the acute phase of her burn. What would be important for the nurse to monitor the patient for? A) Hypometabolism B) Hyponatremia C) Hyperkalemia D) Hypoglycemia

HYPONATREMIA **Hyponatremia is common during the first week of the acute phase, as water shifts from the interstitial space to the vascular space. Hypermetabolism can occur up to 1 year after the burn. Hyperkalemia occurs in the emergent phase of the burn. In a burn patient there is a hyperglycemic response, not a hypoglycemic response.

pt has had serial laboratory tests for the past 3 days to determine adequacy of fluid replacement and the onset of the acute phase of the burn injury. Which of the following lab values would you expect in the emergent phase: 1. Hct: 40%, urine-specific gravity 1.018, serum potassium 3.6 mEq/L 2. Hct: 54%, urine-specific gravity 1.038, serum potassium 6.1 mEq/L

Hct: 54%, urine-specific gravity 1.038, serum potassium 6.1 mEq/L

The nursing students are doing clinical hours on the burn unit. 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. A nursing student asks why this goal is important when the patient is fighting for his life. What should the burn nurse respond? A) To prevent neuropathies B) To prevent wound breakdown C) To prevent contractures D) To prevent heterotopic ossification

PREVENT CONTRACTURES **To prevent the complication of contractures the nurse will establish a goal to maintain position of joints in alignment. Gentle range of motion exercises and a consult to PT and OT for exercises and positioning recommendations are also appropriate interventions for the prevention of contractures.

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 you 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

a, b, 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 "cherry red" skin color.

The nurse is planning care for a patient with partial- and full-thickness skin destruction related to burn injury of the lower extremities. Which of the following interventions would the nurse expect to 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

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. With full-thickness burns, myoglobin and hemoglobin released into the bloodstream can occlude renal tubules. Adequate fluid replacement is used to prevent this occlusion. Pain control is essential in the care of a patient with a burn injury

When assessing a pt 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

a, d, e

A pt in the emergent phase of burn care for thermal burns on 20% of the total body surface area is unconscious. Which assessment data is the most important for the nurse's evaluation of the pt's injuries? a. condition of the oropharynx b. percentage of TBSA affected c. location of the pt in the fire d. comorbidities of the pt

a. the pt is likely to have suffered a smoke inhalation injury because thermal burns are caused by flames that emit smoke and because the pt is unconscious.

The nurse is assessing an Emergency Room patient for evidence of cardiovascular changes associated with deep and full thickness burns. Which of the following would indicate cardiovascular changes as a result of a serious burn? a. Edema formation can be expected in the burn area as a compensatory process from the microcirculation. b. Hypovolumia, slowed capillary circulation and hyperviscosity are evident. c. Increased tissue perfusion in the wound area to attempt to maintain tissue viability in the affected area. d. Peripheral vasodilation decreases perfusion in the affected area.

b. Hypovolumia, slowed capillary circulation and hyperviscosity are evident

Which of the following nursing diagnoses for the patient with a burn Injury has the highest priority during the resuscitative phase? a. Impaired Gas Exchange related to inhalation injury. b. Ineffective airway clearance related to inhalation injury. c. Deficient fluid Volume related to third spacing of fluids. d. Pain related to burn injury.

b. Ineffective airway clearance related to inhalation injury.

b. albuterol stimulates beta adrenergic receptors in the lungs to cause bronchodilation and is nonselective and also causes receptors in the heart to increase heart rate.

A client with burn injury asks the nurse what the term full thickness means. The nurse should respond that burns classified as full thickness involve tissue destruction down to which level? a. epidermis b. dermis c. subcutaneous tissue d. internal organs

c. A full thickness burn involves all skin layers, including the epidermis and dermis, and may extend into the subcutaneous tissue and fat.

When caring for a patient with an electrical burn injury, the nurse should question a health care provider's order for A. Mannitol 75 gm IV. B. Urine for myoglobulin. C. Lactated Ringer's at 25 ml/hr. D. Sodium bicarbonate 24 mEq every 4 hours.

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 at 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.

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 incorrect component of protective isolation technique? a. using sterile sheets and linens b. performing strict hand washing technique c. wearing gloves and gown only when giving direct care to the client d. wearing protective garb, including a mask, gloves, cap, shoe covers, gowns, and plastic apron

c. ppe should be worn whenever entering the client's room

A patient who is admitted to a burn unit is hypovolemic. A new nurse asks an experienced nurse about the patient's condition. Which response if made by the experienced nurse is most appropriate? a) "Blood loss from burned tissue is the most likely cause of hypovolemia." b) "Third spacing of fluid into fluid-filled vesicles is usually the cause of hypovolemia." c) "The usual cause of hypovolemia is vaporation of fluid from denuded body surfaces." d) "Increased capillary permeability causes fluid shifts out of blood vessels and results in hypovolemia."

In caring for a patient with burns to the back, the nurse knows that the patient is moving out of the emergent phase of burn injury when what happens? 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.

d. In the emergent phase, the immediate, life-threatening problems from the burn, hypovolemic shock and edema, are treated and resolved. 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 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 has 25% TBSA burned from a car fire. His wounds have been debrided and covered with a silver-impregnated dressing. Your priority intervention for wound care is to: a. reapply a new dressing without disturbing the wound bed b. observe the wound for signs of infection during dressing changes c. apply cool compresses for pain relief in between dressing changes d. wash the wound aggressively with soap and water three times each day.

d. wash the wound aggressively with soap and water three times each day. Infection is the most serious threat for further tissue injury and possible sepsis.

Test #4 Combo Burns

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