Burns

The goals of management during the emergent period after a burn include which of the following? (Select all that apply.) 1. Airway management 2. Aseptic technique 3. Emotional support 4. Fluid replacement 5. Pain management 6. Rehabilitation

1. Airway management 2. Aseptic technique 3. Emotional support 4. Fluid replacement 5. Pain management

The nurse is determining if a client who sustained a burn should be referred to a burn unit for care. Which of the following types of burn injuries should be referred to this type of care area? (Select all that apply.) 1. Burn on the face 2. Burn to the genitalia 3. Burn to a fractured limb 4. Sunburn 5. Burn caused by hot water to approximately 5 inches of the forearm 6. Burn caused by chemicals

1. Burn on the face 2. Burn to the genitalia 3. Burn to a fractured limb 6. Burn caused by chemicals

Health care professionals are required to report suspected abuse or neglect. Which of the following is not a typical sign of abuse with a burn injury? 1. Emergency management notification of a burn injury within 1 hour of occurrence 2. A burn injury accompanied by fracture and bruises 3. Differing accounts of how the injury occurred with each new interview 4. Treatment sought by a non-relation

1. Emergency management notification of a burn injury within 1 hour of occurrence

A client diagnosed with a major burn is being prescribed medication for pain. The nurse realizes that the drug of choice for this client will be: 1. morphine sulfate. 2. acetaminophen. 3. aspirin. 4. meperidine

1. morphine sulfate.

An adult has a thermal burn injury involving all of one leg and the entire posterior trunk. There are also three scattered areas on the anterior trunk, each approximately the size of the patients palm. As part of initial assessment, the nurse calculates the size of the burn using a combination of the Rule of Nines and the Rule of Palm. What is the result of this calculation in percentage of total body surface area (TBSA)?

39%

The nurse is assessing a client diagnosed with second- and third-degree burns. Which of the following assessment signs would not need to be reported by the nurse? 1. Brassy cough 2. Hoarseness 3. Respiratory rate of 36 4. Urine output of 30 mL in the first hour

4. Urine output of 30 mL in the first hour

The nurse, caring for a client with severe burns, realizes that the clients care will progress through specific periods of treatment EXCEPT: 1. acute period. 2. emergent period. 3. rehabilitation period. 4. stabilization period.

4. stabilization period.

Using the Parkland formula, the fluid needed for a person weighing 140 pounds with a 25% burn would be _____ mL.

6360

A 70 kg patient with burns over 30% of total body surface area (TBSA) is admitted to the burn unit. Using the Parkland formula, calculate the volume of lactated Ringers solution that the nursing staff will administer during the first 24 hours.

8400 mL

The nurse is assessing the patient with a circumferential burn to the left upper extremity. The nurse anticipates the performance of an escharotomy with which of the following assessment findings? Select all that apply. A) Absent distal radial pulses B) Progressive diminution of ultrasound signal C) Limited range of motion D) Decrease in capillary refill E) Pink nail beds

A) Absent distal radial pulses B) Progressive diminution of ultrasound signal D) Decrease in capillary refill

A patient with a large thermal burn has been admitted to the burn intensive care unit. Because the leading cause of death in burned patients after the initial care period is infection, what is the nurses priority action? A) Ensure compliance with hand hygiene protocols by all health care team members. B) Limit visits of legal next of kin to very brief periods of time. C) Adhere to clean aseptic principles during wound care and dressing changes. D) Collect environmental cultures and wound cultures as scheduled.

A) Ensure compliance with hand hygiene protocols by all health care team members.

The patient has an acute burn injury. What might be the cause of the burn trauma? Select all that apply. A) Pot of boiling water pulled off a stove B) Crockpot full of beans spilled C) House or room fire D) Absence of electrical power E) Exposure to anhydrous ammonia F) Contact with white phosphorus

A) Pot of boiling water pulled off a stove B) Crockpot full of beans spilled C) House or room fire E) Exposure to anhydrous ammonia F) Contact with white phosphorus

A patient has been treated for severe burns over 36% of the body. What assessment data obtained by the nurse indicates the patient may be experiencing septic shock? (Select all that apply.) A) White blood count (WBC) 7,200 B) Blood pressure 60/40 C) PaO2 72 D) Urine output <10 mL/hour E) Blood pressure 140/76

B) Blood pressure 60/40 C) PaO2 72 D) Urine output <10 mL/hour

The nurse is caring for a patient 24 hours after fluid resuscitation for burns over 50% of the body. Which assessment data obtained by the nurse indicates complications from the fluid resuscitation? A) Absent peripheral pulses B) Crackles in lung fields C) Sinus bradycardia D) 1+ pitting edema of the feet

B) Crackles in lung fields

A patient has had an alkali splash causing burns to the right upper extremity and the right side of the face. Which intervention by the nurse is a priority? A) Obtain a health history. B) Irrigate with water to the burned area. C) Apply an antibiotic cream. D) Start an intravenous line (IV) of normal saline at 10 mL/hr.

B) Irrigate with water to the burned area.

A patient has a large thermal burn injury and is receiving large amounts of intravenous crystalloid fluid as part of initial therapy. What is the best explanation of the purpose of this therapy? A) It is part of the protocol for initial burn management. B) Burn trauma cell damage causes external fluid loss. C) Development of third spacing reduces renal perfusion. D) Crystalloid intravenous fluids are less expensive.

C) Development of third spacing reduces renal perfusion.

The patient has a superficial partial-thickness (second-degree) burn. What characteristic unique to this type of burn does the nurse expect to find? A) Bright red color B) Surface moist and supple C) Fluid-filled blisters D) High pain level

C) Fluid-filled blisters

A patient arrived in the emergency department (ED) after being found by a family member unconscious in the garage with the car running. High flow oxygen at 100% is administered in the ED. The nurse knows that which of the following diagnostic tests would be the best to determine that the present therapy is effective? A) Pulse oximetry B) Chest x-ray C) Serial carboxyhemoglobin levels D) Hemoglobin and hematocrit

C) Serial carboxyhemoglobin levels

The patient has a large burn wound that is mostly a full-thickness (third-degree) injury. Wound care included surgical excision and grafting with a variety of materials. The patient and family ask the nurse to explain why repeated surgical procedures are necessary. What is the best explanation the nurse can give the family? A) Because of pain and surgical shock, the repair is done in stages. B) The surgeon is the appropriate person to answer this question. C) Successful autografting requires preparation of the wound bed. D) Lack of patient compliance has reduced the effectiveness of autografting.

C) Successful autografting requires preparation of the wound bed.

A patient is admitted into the emergency department with the complaint, I burned my hand. I didnt realize the stove top was still so hot. The palmar surface of the hand is blistered, red, and blanches. What type of burn does the nurse document this patient has? A) Superficial B) Deep partial thickness C) Superficial partial thickness D) Full thickness

C) Superficial partial thickness

A patient has a large burn injury that occurred in an enclosed space. On initial assessment, the patient is found to have erythema and blistering of the mouth and pharynx, hoarse speech, and tachypnea. What immediate therapy addressing these symptoms does the nurse anticipate? A) Intravenous fluid resuscitation B) Prophylactic antimicrobial therapy C) Application of topical burn medications D) Endotracheal intubation

D) Endotracheal intubation

The underlying pathophysiology of a burn trauma centers around what? A) Location of burn damage B) Zone of coagulation C) Maximum exposure temperature D) Extent of cellular injury and death

D) Extent of cellular injury and death

In a motor vehicle crash, a patient suffers a skull fracture, possible cervical spine injury, multiple extremity fractures, and a large thermal burn. On initial admission to the emergency department, what is the nursing priority of care? A) Intravenous fluid resuscitation B) Protection from infection C) Assessment of extent of burns D) Protection of airway and cervical spine

D) Protection of airway and cervical spine

The interventions for a burn patient newly admitted to the emergency department include: (Select all that apply.) a. covering the burn with sterile salinesaturated towel. b. removing clothing stuck to burn. c. taking care not to disturb blisters. d. removing jewelry from injured limbs. e. assessing the cause of the burn.

a. covering the burn with sterile salinesaturated towel. c. taking care not to disturb blisters. d. removing jewelry from injured limbs. e. assessing the cause of the burn.

To maintain adequate nutrition for a patient who has just been admitted with a 40% total body surface area (TBSA) burn injury, the nurse will plan to 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.

a. insert a feeding tube and initiate enteral feedings.

An autograft is used to optimally treat a partial- or full-thickness wound that: (Select all that apply.) a. involves a joint. b. involves the face, hands, or feet. c. is infected. d. requires more than 2 weeks for healing.

a. involves a joint. b. involves the face, hands, or feet. d. requires more than 2 weeks for healing.

The nurse is caring for a patient with a chemical burn injury. The priority nursing intervention is to: a. remove the patients clothes and flush the area with water. b. apply saline compresses. c. contact a poison control center for directions on neutralizing agents. d. remove all jewelry.

a. remove the patients clothes and flush the area with water.

A patient wants to know how long it will take to know if a skin graft used to cover a burn site is successful. How many days should the nurse explain as needed for graft vascularization to occur? a. 1 to 2 b. 3 to 5 c. 7 to 9 d. 11 to 13

b. 3 to 5

A patient is diagnosed with superficial partial-thickness burns. How many days should the nurse instruct the patient that these burns will need to heal? a. 1 to 5 b. 7 to 10 c. 14 to 21 d. 28 to 45

b. 7 to 10

The nurse is caring for a patient who has circumferential full-thickness burns of his forearm? A priority in the plan of care is : a. Keeping the extremity in a dependent position b. Active and passive range of motion every hour. c. Preparing for an escharotomy as a prophylactic measure d. Splinting the forearm

b. Active and passive range of motion every hour.

An elderly individual from an assisted living facility presents with severe scald burns to the buttocks and back of the thighs. The caregiver from the ALF accompanies the patient to the emergency department and states that the bath water was too hot and that the patient sat in the water too long. What should the nurse do? a. Ask the caregiver at what temperature the water heater is set in the home. b. Ask the caregiver to step out while examining the patients burn injury. c. Immediately contact the police to report the suspected elder abuse. d. Ask the caregiver to describe exactly how the injury occurred

b. Ask the caregiver to step out while examining the patients burn injury.

Which of the following factors increase the burn patients risk for venous thromboembolism? (Select all that apply.) a. Burn injury less than 10% b. Bedrest c. Burns to lower extremities d. Electrical burn injury e. Delayed fluid resuscitation

b. Bedrest c. Burns to lower extremities e. Delayed fluid resuscitation

A victim of a fire in a manufacturing plant is brought to the emergency department. The HCP suspects this victim has sustained an inhalation injury. Which tests should the nurse expect to be prescribed for this patient? (Select all that apply.) a. Chest x-ray b. Bronchoscopy c. Arterial blood gases d. CT scan of the thorax e. Carboxyhemoglobin level

b. Bronchoscopy c. Arterial blood gases e. Carboxyhemoglobin level

The nurse is preparing to apply dressings to a patients partial-thickness burn wounds. What should the nurse keep in mind when applying these dressings? (Select all that apply.) a. Wrap digits as one dressing. b. Elevate affected extremities. c. Limit the amount of dressing bulk. d. Wrap extremities from distal to proximal. e. Double the estimated size of dressing material.

b. Elevate affected extremities. c. Limit the amount of dressing bulk. d. Wrap extremities from distal to proximal.

Patients with burns may have mesh grafts or sheet grafts. Which of the following sites is most likely to have a sheet graft applied? a. Arm b. Face c. Leg d. Chest

b. Face A sheet graft is more likely to be used on the face and hands because the cosmetic effects are more optimal. Meshed grafts are more commonly used elsewhere on the body (e.g., arm, leg, chest, etc.)

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). Which action will the nurse anticipate taking? a. Continue to monitor the laboratory results. b. Increase the rate of the ordered IV solution. c. Type and crossmatch for a blood transfusion. d. Document the findings in the patients record

b. Increase the rate of the ordered IV solution.

When paramedics notice singed hairs in the nose of a burn patient, it is recommended that the patient be intubated. What is the reasoning for the immediate intubation? a. Carbon monoxide poisoning always occurs when soot is visible. b. Inhalation injury above the glottis may cause significant edema that obstructs the airway. c. The patient will have a copious amount of mucus that will need to be suctioned. d. The singed hairs and soot in the nostrils will cause dysfunction of cilia in the airways

b. Inhalation injury above the glottis may cause significant edema that obstructs the airway.

The nurse is assisting with the care of a patient admitted to the emergency department with chemical burns across the chest and hands. Which actions should be included in the plan of care? (Select all that apply.) a. Apply ice packs to burn sites. b. Remove all contaminated clothing. c. Cover the patient with a clean sheet. d. Apply neutralizing agent to burn area. e. Obtain a history of the event and burning agent. f. Provide copious tepid water lavage for 20 minutes

b. Remove all contaminated clothing. c. Cover the patient with a clean sheet. e. Obtain a history of the event and burning agent. f. Provide copious tepid water lavage for 20 minutes

The nurse understands that negative-pressure wound therapy may be used in the treatment of partial-thickness burn wounds to do which of the following? a. Maintain a closed wound system to decrease the risk of infection. b. Remove excessive wound fluid and promote moist wound healing. c. Increase patient mobility with large burn wounds. d. Quantify wound drainage amount for more accurate output assessment.

b. Remove excessive wound fluid and promote moist wound healing.

Which of these nursing actions should be done first 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

b. Stabilize the cervical spine.

A(An) ____________________ often produces a superficial cutaneous injury but may cause cardiopulmonary arrest and transient but severe central nervous system deficits. a. chemical burn b. electrical burn c. heat burn d. infection

b. electrical burn

Silver is used as an ingredient in many burn dressings because it: a. stimulates tissue granulation. b. is effective against a wide spectrum of wound pathogens. c. provides topical pain relief. d. stimulates wound healing.

b. is effective against a wide spectrum of wound pathogens.

The nurse is caring for a patient with burns covering the entire surface of both arms and the anterior trunk. Approximately what percentage of the patients body surface area has been affected? a. 18% b. 27% c. 36% d. 45%

c. 36%

A patient has burns on both legs and in the genital/perineum area. What is this patients percentage of burned area? a. 18% b. 19% c. 37% d. 54%

c. 37%

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, the nurse will decrease the fluid infusion rate to a. 350 mL/hour. b. 523 mL/hour. c. 938 mL/hour. d. 1250 mL/hour.

c. 938 mL/hour.

The nurse is conducting an admission assessment of an 82-year-old patient who sustained a 12% burn from spilling hot coffee on the hand and arm. Which statement is of priority to assist in planning treatment? a. Do you live alone? b. Do you have any drug or food allergies? c. Do you have a heart condition or heart failure? d. Have you had any surgeries?

c. Do you have a heart condition or heart failure?

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

c. Extremity movement

The Parkland fluid resuscitation calculation calls for 8000 mL. The burn occurred at noon. The present time is 2:00 PM. The fluid should be set to deliver _____ mL by _____ PM. a. 2000, 6:00 b. 3000, 7:00 c. 4000, 8:00 d. 7000, 9:00

d. 7000, 9:00

The nurse is caring for a patient in the initial phase of treatment for a partial-thickness burn. The patient has been stabilized, with blood pressure 140/88 mm Hg, pulse 78 beats/min, respirations 22 breaths/min, and temperature 97.4F (36.3C). Which new assessment finding should be immediately communicated to the health care provider (HCP)? a. Report of increasing pain b. Temperature 99F (37.2C) c. Serum-filled blister formation d. Blood pressure 122/74 mm Hg

d. Blood pressure 122/74 mm Hg

A patient is having a surgical procedure done to promote peripheral tissue perfusion in an extremity with full-thickness circumferential burns. What term should the nurse use to document this procedure? a. Excision b. Skin graft c. Dbridement d. Escharotomy

d. Escharotomy

During the emergent phase of burn care, which nursing action 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

d. Measure hourly urine output

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. Hct 52% b. BUN 36 mg/dL c. Serum sodium 146 mEq/L d. Serum potassium 6.2 mEq/L

d. Serum potassium 6.2 mEq/L

The nurse is planning care to meet the patients pain management needs related to burn treatment. The patient is alert, oriented, and follows commands. The pain is worse during the day when various treatments are scheduled. Which statement to the physician best indicates the nurses knowledge of pain management for this patient? a. Can we ask the music therapist to come by each morning to see if that will help the patients pain? b. The patients pain is often unrelieved. I suggest that we also add benzodiazepines to the opioids around the clock. c. The patients pain is often unrelieved. It would be best if we can schedule the opioids around the clock. d. The patients pain varies depending on the treatment given. Can we try patient-controlled analgesia to see if that helps the patient better?

d. The patients pain varies depending on the treatment given. Can we try patient-controlled analgesia to see if that helps the patient better?

The nurse is caring for a patient with an electrical injury. The nurse understands that patients with electrical injury are at a high risk for acute kidney injury secondary to: a. hypervolemia from burn resuscitation. b. increased incidence of ureteral stones. c. nephrotoxic antibiotics for prevention of infection. d. release of myoglobin from injured tissues

d. release of myoglobin from injured tissues

The nurse is providing care to manage the pain of a patient with burns. The physician has ordered opiates to be given intramuscularly. The nurse contacts the physician to change the order to intravenous administration because: a. intramuscular injections cause additional skin disruption. b. burn pain is so severe it requires relief by the fastest route available. c. hypermetabolism limits effectiveness of medications administered intramuscularly. d. tissue edema may interfere with drug absorption of injectable routes

d. tissue edema may interfere with drug absorption of injectable routes

A client who has experienced a burn is in the emergent phase of treatment that usually occurs during which of the following periods? 1. 24 to 48 hours 2. 36 to 72 hours 3. 48 to 96 hours 4. 1 to 7 days

1. 24 to 48 hours

A client has been diagnosed with a full-thickness burn injury to the hands and arms. Which of the following characteristics would the nurse expect to find? (Select all that apply.) 1. Blanches with fingertip pressure 2. Charred vessels visible under eschar 3. Many blisters that increase in size 4. Nerve endings dead 5. No edema 6. Very painful

2. Charred vessels visible under eschar 4. Nerve endings dead

The nurse is preparing to provide wound care to a client newly diagnosed with a burn. Which of the following are goals of this initial wound care? (Select all that apply.) 1. Hydrate the skin. 2. Cleanse the skin. 3. Prevent further skin destruction. 4. Provide comfort. 5. Prevent nutritional deficits. 6. Prevent infection.

2. Cleanse the skin. 3. Prevent further skin destruction. 4. Provide comfort. 6. Prevent infection.

An individuals sleeve catches on fire while cooking. He runs through the kitchen and out the back door. Which of the following interventions should the family perform? (Select all that apply.) 1. Have the individual stand for easy access. 2. Remove any loose debris. 3. Remove clothing adhered to the burned area. 4. Remove jewelry. 5. Use the water hose to cool the burn. 6. Cover the burned areas with a clean dry material

2. Remove any loose debris. 4. Remove jewelry. 5. Use the water hose to cool the burn. 6. Cover the burned areas with a clean dry material

The nurse is estimating the extent of a burn using the rule of nines for a patient who has been admitted with deep partial-thickness burns of the posterior trunk and right arm. What percentage of the patients total body surface area (TBSA) has been injured?

27%

The formula used to calculate the volume of intravenous (IV) fluid required for fluid resuscitation of a client receiving care in the first 24 hours after a burn is: 1. 1 to 2 mL of lactated Ringers solution body weight percent burn. 2. 2 to 3 mL of lactated Ringers solution body weight percent burn. 3. 2 to 4 mL of lactated Ringers solution body weight percent burn. 4. 3 to 6 mL of lactated Ringers solution body weight percent burn.

3. 2 to 4 mL of lactated Ringers solution body weight percent burn.

A client is being evaluated in the emergency department following a burn injury at home. The client has second- and third-degree burns to the right and left arms, back, and both posterior legs. Using the rule of nines, the nurse would calculate this clients burn as being: 1. 36%. 2. 45%. 3. 54%. 4. 63%.

3. 54%.

A client is beginning the initial treatment of a major burn in the emergency room. Which of the following interventions would not be completed? 1. Inserting an indwelling urinary catheter 2. Intubatng the patient 3. Giving oral medications for pain management 4. Starting an intravenous solution of Ringers lactate

3. Giving oral medications for pain management

A client is scheduled to receive a skin graft from another species as part of the treatment for a burn wound. Which of the following is a graft of skin obtained from another species? 1. Allograft 2. Autograft 3. Heterograft 4. Homograft

3. Heterograft (xenograft)

The nurse is initiating care for a client diagnosed with burns to the chest, back, neck, and face. For this client, which of the following nursing diagnoses would receive the highest priority? 1. Disturbed body image 2. Impaired skin integrity 3. Ineffective airway clearance 4. Risk for infection

3. Ineffective airway clearance

Which of the following will the nurse most likely assess in a client diagnosed with a second-degree burn? 1. No pain and necrotic areas 2. No pain and scarring 3. Pain and blisters 4. Pain and peeling after 2 to 5 days

3. Pain and blisters

An adult male patient enters the emergency department with full- and partial-thickness burns on the entire right leg, front of the right arm, and one half of the front torso. The nurse, using the rule of nines, assesses the burn as ____%.

31.5%

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

a. Notify the health care provider.

To prevent contractures in the burn patient, the nurse should: a. assist the patient to ambulate as soon as fluid shift has stabilized. b. leave the limbs in full extension. c. stop range-of-motion (ROM) exercises when the patient complains of pain. d. place the limbs in the flexion position.

a. assist the patient to ambulate as soon as fluid shift has stabilized.

Which of the following statements about the pain management of a burn victim are true? (Select all that apply.) a. Additional pain medication may be needed because of rapid body metabolism. b. Pain medication should be given before procedures such as debridement, dressing changes, and physical therapy. c. Patients with a history of drug and alcohol abuse will require higher doses of pain medication. d. The intramuscular route is preferred for pain medication administration.

a. Additional pain medication may be needed because of rapid body metabolism. b. Pain medication should be given before procedures such as debridement, dressing changes, and physical therapy. c. Patients with a history of drug and alcohol abuse will require higher doses of pain medication.

Which of the following infection control strategies should the nurse implement to decrease the risk of infection in the burn-injured patient? (Select all that apply.) a. Apply topical antibacterial wound ointments/dressings. b. Change indwelling urinary catheter every 7 days. c. Daily assess the need for central IV catheters. d. Restrict family visitation. e. Maintain strict aseptic technique during burn wound management.

a. Apply topical antibacterial wound ointments/dressings. c. Daily assess the need for central IV catheters. e. Maintain strict aseptic technique during burn wound management.

The nurse is caring for a patient with burns to the hands, feet, and major joints. The nurse plans care to include which of the following? (Select all that apply.) a. Applying splints that maintain the extremity in an extended position b. Implementing passive or active range-of-motion exercises c. Keeping the limbs as immobile as possible d. Wrapping fingers and toes individually with bandages

a. Applying splints that maintain the extremity in an extended position b. Implementing passive or active range-of-motion exercises d. Wrapping fingers and toes individually with bandages

The nurse is preparing a patient with 46% total body surface area burned for graft placement. Which anatomical locations should the nurse expect to have a lower rate of graft success than other areas of the body? (Select all that apply.) a. Axillae b. Buttocks c. Perineum d. Forearms e. Abdomen f. Joint areas

a. Axillae b. Buttocks c. Perineum f. Joint areas

The nurse is caring for a patient who sustained a partial-thickness burn to the face. Which assessment findings should the nurse expect? (Select all that apply.) a. Blisters b. Charred skin c. White patches d. Bright red color e. Leathery character f. Blanching when touched

a. Blisters d. Bright red color f. Blanching when touched

The nurse is caring for patient who has been struck by lightning. Because of the nature of the injury, the nurse assesses the patient for which of the following? a. Central nervous system deficits b. Contractures c. Infection d. Stress ulcers

a. Central nervous system deficits

A patient with a partial thickness burn wound is prescribed synthetic dressings. What should the nurse explain to the patient about this type of dressing? (Select all that apply.) a. Easier to store b. Cost less to use c. Readily available d. Come in various shapes e. Contain antimicrobial substances

a. Easier to store b. Cost less to use c. Readily available d. Come in various shapes

The nurse is caring for a patient with extensive burns. For which systemic responses to the burn should the nurse monitor the patient? (Select all that apply.) a. Hypovolemia b. Peptic ulceration c. Decreased metabolism d. Increased platelet function e. Increased oxygen consumption f. Depression of immunoglobulins

a. Hypovolemia b. Peptic ulceration e. Increased oxygen consumption f. Depression of immunoglobulins

Which complications may manifest after an electrical injury? (Select all that apply.) a. Long bone fractures b. Cardiac dysrhythmias c. Hypertension d. Compartment syndrome of extremities e. Dark brown urine f. Peptic ulcer disease g. Acute cataract formation h. Seizures

a. Long bone fractures b. Cardiac dysrhythmias d. Compartment syndrome of extremities e. Dark brown urine g. Acute cataract formation h. Seizures

The nurse notes that a patient with full thickness burns has an increase in hematocrit level. What should the nurse realize is causing this change in laboratory value? a. Loss of intravascular fluid b. Destruction of blood vessels c. Increased function of platelets d. Migration of white blood cells

a. Loss of intravascular fluid

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

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

The patient asks the nurse if the placement of the autograft over his full-thickness burn will be the only surgical intervention needed to close his wound. The nurses best response would be: a. Unfortunately, an autograft skin is a temporary graft and a second surgery will be needed to close the wound. b. An autograft is a biological dressing that will eventually be replaced by your body generating new tissue. c. Yes, an autograft will transfer your own skin from one area of your body to cover the burn wound. d. Unfortunately, autografts frequently do not adhere well to burn wounds and a xenograft will be necessary to close the wound.

c. Yes, an autograft will transfer your own skin from one area of your body to cover the burn wound.

The optimal measurement of intravascular fluid status during the immediate fluid resuscitation phase of burn treatment is: a. blood urea nitrogen. b. daily weight. c. hourly intake and urine output. d. serum potassium

c. hourly intake and urine output.

In patients with extensive burns, edema occurs in both burned and unburned areas because of: a. catecholamine-induced vasoconstriction. b. decreased glomerular filtration. c. increased capillary permeability. d. loss of integument barrier.

c. increased capillary permeability.

Tissue damage from burn injury activates an inflammatory response that increases the patients risk for: a. acute kidney injury. b. acute respiratory distress syndrome. c. infection. d. stress ulcers.

c. infection.

A patient with a 60% burn in the acute phase of treatment develops a tense abdomen, decreasing urine output, hypercapnia, and hypoxemia. Based on this assessment, the nurse anticipates interventions to evaluate and treat the patient for: a. acute kidney injury. b. acute respiratory distress syndrome. c. intraabdominal hypertension. d. disseminated intravascular coagulation disorder

c. intraabdominal hypertension.

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. white blood cell levels decrease. b. blisters and edema have subsided. c. the patient has large quantities of pale urine. d. the patient has been hospitalized for 48 hours.

c. the patient has large quantities of pale urine.