BURNS EVERYTHING
The nurse is assisting with the secondary survey of a patient with 50% total body surface area electrical burns. Which test would be a priority for this patient? 1) Chest x-ray 2) Bronchoscopy 3) CT scan of the head 4) 12-lead electrocardiogram
ANS: 4 A 12-lead electrocardiogram is indicated for an electrical injury.
It is documented that a patient has superficial partial-thickness burns over both anterior lower arms. What should the nurse expect when assessing this patient? 1) Dry with no blisters 2) Waxy appearance and cherry red in color 3) Dry leathery appearance and pale or brown in color 4) Open or closed blisters, mild edema, easily blanches
ANS: 4 A superficial partial-thickness burn has blisters that may be closed or open and weeping; pink or red; mild edema; and blanches easily.
A client with burn injuries states, "I feel so helpless." Which nursing intervention is most helpful for this client? A Encouraging participation in wound care B Encouraging visitors C Reassuring the client that he or she will be fine D Telling the client that these feelings are normal
A Encouraging participation in wound care will offer the client some sense of control. Encouraging visitors may be a good distraction, but will not help the client achieve a sense of control. Reassuring the client that he or she will be fine is neither helpful nor therapeutic. Telling the client that his or her feelings are normal may be reassuring, but does not address the client's issue of feeling helpless.
A newly admitted client has deep partial-thickness burns. The nurse expects to see which clinical manifestations? A) Painful red and white wounds B) Painless, brownish yellow eschar C) Painful reddened blisters D) Painless black skin with eschar
A A painful red and white wound bed characterizes deep partial-thickness burns; blisters are rare. Painless, brownish yellow eschar characterizes a full-thickness burn. A painful reddened blister is seen with a superficial partial-thickness burn. Painless black skin with eschar is seen in a deep full-thickness burn.
The nurse is caring for a client with a burn injury who is receiving silver 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
A Topical antimicrobials such as silver sulfadiazine are an important intervention for infection prevention in burn wounds. Topical antimicrobials such as silver 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 is in the resuscitation 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
B During the resuscitation 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 sublingual route may not be effective, and because the skin is too damaged, the topical route is not indicated for administering drugs to the client in the resuscitation phase of burn injury.
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? 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
C Fluid resuscitation is provided at the rate needed to maintain urine output at 30 to 50 mL/hr 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.
A patient comes into the emergency room seeking treatment for radiation burns. What should be considered prior to providing care to this patient? 1) Pathway of flow through the body 2) Duration of contact with the agent 3) Type, dose, and length of exposure 4) Temperature to which the skin is heated
ANS: 3 The severity of a radiation burn is dependent upon the type, dose, and length of exposure.
A patient recovering from 25% total body surface area burns has a low-grade fever. What should the nurse do to reduce this patient's risk of developing an infection? 1) Follow contact precautions 2) Implement protective isolation 3) Use sterile technique for all dressing changes 4) Administer prophylactic antibiotics as prescribed
ANS: 1 Cross-contamination among burn patients is common, and as a result, isolation guidelines are widespread practices among burn centers. Contact precautions may be used when entering all patient rooms.
A patient with 35% total body surface area burns is in the rehabilitative phase of care. Which approach should be used to reduce the risk of developing contractures? 1) Apply splints 2) Physical therapy two hours a day 3) Passive range of motion exercises 4) Occupational therapy one hour every other day
ANS: 1 Splinting is the most common method used to help prevent the formation of contractures.
A patient with several deep partial-thickness burns asks how long it will take for the burn to heal. What should the nurse respond to this patient? 1) "More than two weeks." 2) "Within one to two weeks." 3) "Within 24 to 72 hours." 4) "You will need skin grafts."
ANS: 1 The majority of deep partial-thickness burns take more than two weeks to heal.
The nurse is caring for a patient who sustained chemical burns. What would have caused these injuries? Select all that apply. 1) Lime 2) Gasoline 3) Bleach 4) Fabric softener 5) Hydrofluoric acid
ANS: 1, 2, 3, 5 1. Lime can cause a chemical burn. 2. Gasoline can cause a chemical burn. 3. Bleach can cause a chemical burn. 5. Hydrofluoric acid can cause a chemical burn.
A patient is diagnosed with several superficial partial-thickness burns. What treatment would be indicated for this patient? Select all that apply. 1) Apply bacitracin ointment 2) Cover with a nonadherent bandage 3)Apply mafenide acetate 10% cream 4)Wash with antiseptic soap and warm water 5)Apply collagenase and cover with roll gauze
ANS: 1, 2, 4 1. Care of a superficial partial-thickness burn includes applying bacitracin ointment. 2. Care of a superficial partial-thickness burn includes covering with nonadherent bandage. 4. A superficial partial-thickness burn is to be washed with antiseptic soap and warm water.
A patient has been recovering for 18 months from burns that affected 60% total body surface area. For which problems should the nurse anticipate providing continuing care to this patient? Select all that apply. 1) Anxiety 2) Depression 3) Spiritual distress 4) Body image disorder 5) Post-traumatic stress disorder (PTSD)
ANS: 1, 2, 4, 5 The burn patient may endure many psychological and emotional challenges throughout his or her lengthy course of treatment and recovery. The patient may experience anxiety, depression, body image disorder, and PTSD.
A patient has full-thickness burns over 30% of total body surface area. Which intervention will least likely provide comfort initially to this patient? 1) Elevate injured extremities 2) Medicate for pain around the clock 3) Apply medicated ointment to all areas 4) Elevate the head of the bed 30 degrees
ANS: 2 A full-thickness burn involves destruction of the epidermis, the dermis, and portions of the subcutaneous tissue. All epidermal and dermal structures are destroyed including hair follicles, sweat glands, and nerve endings. As a result of the extensive damage to the nerve endings, full-thickness burns are insensate to palpation and often are not painful. Pain medication would be least likely to provide comfort to this patient initially.
The nurse is evaluating nutritional teaching provided to a patient recovering from 24% total body surface area burns. Which information indicates that teaching has been effective? 1) Weight loss 3 kg 2) Serum protein level 7.1 g/dL 3) Serum albumin level 2.8 g/dL 4) +1 pitting edema of lower extremities
ANS: 2 A normal serum protein level is 6.4 to 8.3 g/dL.
The nurse is caring for a patient with 70% total body surface area chemical burns. Which approach should the nurse anticipate to meet this patient's nutritional needs? 1) Parenteral nutrition 2) Duodenal tube feedings 3) Nasogastric tube feedings 4) Six small high-calorie meals per day
ANS: 2 In large burn injuries, longer nutritional support is required, and placement of a duodenal feeding tube is often recommended to help prevent aspiration and allow for feeding up to and during procedures.
The nurse is caring for a patient with 45% total body surface area thermal burns. Which laboratory value change would be expected? 1) Increased pH 2) Increased sodium 3) Increased potassium 4) Decreased hematocrit
ANS: 3 Hyperkalemia is expected because of massive cellular trauma causing the release of potassium into extracellular fluid.
A victim of a house fire is brought to the emergency department for burn treatment. What assessment finding indicates that the patient may have an inhalation injury? 1) Coughing 2) Soot on the face 3) Singed facial hair 4) Heart rate 98 bpm
ANS: 3 Patients with an inhalation injury may present with singed facial hair.
A patient is ending the first year of recovery after having burns to both legs. Which observation indicates that the patient needs to be encouraged to wear the pressure garment? 1) Skin warm and moist 2) Pedal pulses present but faint 3) Scattered areas of scarring noted 4) Nonpitting edema of both ankles
ANS: 3 Specialty pressure garments are intended to provide continuous and uniform pressure over the area of burn to prevent hypertrophic scarring. These garments are to be worn 23 hours a day for up to a year or more after injury in some patients. The presence of scarring indicates the garment has not been worn consistently.
A patient with 55% total body surface area burned received two-thirds of the required fluid resuscitation. For which potential problem should the nurse prepare to provide care to this patient? 1) Increased zone of stasis 2) Increased zone of hyperemia 3) Increased zone of coagulation 4) Decreased zone of coagulation
ANS: 3 The zone of stasis immediately surrounds the zone of coagulation and is characterized by damaged cells and impaired circulation. It is this area of the burn that is most at risk for conversion if the patient does not receive adequate resuscitation. Improper resuscitation or under-resuscitation may cause the burn to become deeper because of limited blood flow, causing the zone of stasis to convert into the zone of coagulation.
A victim of a car fire is confused, dizzy, and nauseated. What diagnostic test should be done to determine if this patient is experiencing carbon monoxide poisoning? 1) Chest x-ray 2) Bronchoscopy 3) Pulse oximeter 4) Carboxyhemoglobin level
ANS: 4 Because carbon monoxide binds to the hemoglobin molecule with an affinity 200 times greater than that of oxygen, tissue hypoxia results when carbon monoxide levels are above normal. Carboxyhemoglobin levels will detect the amount of carbon monoxide in the patient.
A patient is admitted for a suspected inhalation injury. What should the nurse emphasize when caring for this patient? 1) Increase oral fluids 2) Turn in bed every two hours 3) Monitor strict intake and output 4) Deep breathing and coughing every hour
ANS: 4 Deep breathing and coughing should be done every hour to assist with airway clearance and mobilization of secretions.
The nurse is caring for a patient with 50% total body surface area burns. Which finding indicates that burn shock is resolving? 1) Heart rate 112 bpm 2) Respirations 24 per minute 3) Blood pressure 90/60 mm Hg 4) Urine output 800 mL over 2 hours
ANS: 4 In the postburn shock phase, which begins 24 to 48 hours after injury, the capillaries begin to regain integrity. Burn shock slowly begins to resolve, and the fluid gradually returns to the intravascular space. Urinary output continues to increase secondary to patient diuresis.
The nurse is evaluating care provided to a patient with burns during the emergent phase. Which data indicates that additional fluid resuscitation is required? 1) Blood pH 7.39 2) Heart rate 112 bpm 3) Blood pressure 110/60 mm Hg 4) Central venous pressure 2 mm Hg
ANS: 4 Indications of adequate fluid resuscitation include a central venous pressure between 5-10 mm Hg. A pressure of 2 mm Hg indicates fluid volume deficit. More fluid would be indicated.
The nurse is caring for a patient who sustained electrical burns. Why should the nurse monitor this patient for compartment syndrome? 1) Potential for undiagnosed injuries 2) Injuries from being thrown bruise soft tissue 3) Electrical current alters integrity of blood vessels 4) Fluid seeps from intravascular spaces into the interstitium
ANS: 4 Pulses are closely monitored in all affected extremities for the first 48 hours postinjury in order to assess for the potential development of compartment syndrome. As fluid seeps from the intravascular spaces into the interstitium, pressure within the tissues continues to rise and confines swelling inside muscle compartments.
When hemodynamic status is monitored in a patient with a burn injury, what amount of urine output indicates adequate fluid resuscitation? A. 0.5 mL/kg/hr B. 1 mL/kg/hr C. 2 mL/kg/hr D. 3 mL/kg/hr
Answer: A Rationale: Adequate urine output of 0.5 ml/kg/hr is crucial in a burn patient to maintain tissue perfusion and organ function.
A patient is admitted to the emergency room after sustaining a flash burn to his face. He presents with facial burns and singed nasal hair but is reporting no difficulty breathing. The nurse places the patient on 100% oxygen via face mask. Upon reassessment, the nurse notes that his voice has changed and the patient is reporting difficulty swallowing. What is the most appropriate nursing action? A. Notify the physician and anticipate endotracheal intubation. B. Obtain a chest radiograph. C. Administer a bronchodilator. D. Lower the rate of the patient's intravenous fluids
Answer: A Rationale: Patients who have sustained an inhalation injury may have difficulty swallowing and report hoarseness and/or a change in voice.
The nurse correlates which zone of burn injury as the most susceptible to sustained injury because of insufficient fluid resuscitation? A. Zone of stasis B. Zone of conversion C. Zone of hyperemia D. Zone of coagulation
Answer: A Rationale: The zone of stasis immediately surrounds the zone of coagulation and is characterized by damaged cells and impaired circulation. It is this area of the burn that is most at risk for conversion if the patient does not receive adequate resuscitation. The zone of coagulation is the area that has the most contact with the heat source and is the location of the most severe damage. The outermost area is termed the zone of hyperemia and is generally an area of increased blood flow in an effort to bring key nutrients for tissue recovery.
The nurse correlates which clinical manifestations to the possibility of an inhalation injury? (Select all that apply.) A. Facial burns B. Singed nasal hairs C. Soot in the sputum D. Hoarseness E. Eschar
Answer: A, B, C, and D Rationale: Patients that have sustained an inhalation injury may have facial burns, singed nasal hairs, soot in their sputum, and hoarseness caused by edema and irritation. An abnormal EKG is not indicative of an inhalation injury.
The nurse anticipates supplementary feeding via a nasogastric tube in a patient for which reasons? (Select all that apply.) A. Hypermetabolic state B. Multiple open wounds C. Increased heat loss D. Increased caloric needs E. Burn greater than 20% TBSA
Answer: A, B, D, and E Rationale: Supplemental nutrition should be considered for any burn patient who has sustained a burn greater than 20% TBSA. In addition, burn patients have open wounds and are in a hypermetabolic state, resulting in increased caloric needs.
Using the Parkland formula, the nurse determines that a patient requires a total of 12 L of fluid in the first 24 hours post injury. How much of the total volume needs to be given within the first 8 hours? A. 4,000 mL lactated Ringer's B. 6,000 mL lactated Ringer's C. 8,000 mL lactated Ringer's D. 10,000 mL lactated Ringer's
Answer: B Rationale: According to the Parkland Formula, half of the total calculated volume is given within the first 8 hours.
The nurse recognizes which diagnostic test as most sensitive in a patient with a suspected electrical burn injury? A. Arterial blood gas B. CK-MB levels C. Echocardiogram D. Serum carboxyhemoglobin
Answer: B Rationale: For electrical injuries, it is important to obtain a baseline EKG, troponin and CK-MB levels. A serum carboxyhemoglobin level is obtained on all patients with suspected inhalation injuries. Arterial blood gases are important to monitor overall respiratory status, but are not selective to electrical injuries. Likewise, an echocardiogram is indicated for assessment of cardiac function that would not be immediate in the patient after a burn injury.
Which intervention is the priority for the patient during the emergent phase of burn management? A. Application of silver sulfadiazine cream B. Use of clean, dry sheets and warm blankets C. Initiation of wet normal saline dressings D. Maintaining the injured area open to air
Answer: B Rationale: The burn wound is not the first priority during the emergent resuscitative phase as more life-threatening issues often take precedence. The burn wound is covered with clean, dry blankets to prevent hypothermia, but the initiation of wound care may be delayed for several hours until the patient is stabilized.
The nurse recognizes which etiology as consistent with a thermal burn? A. Direct current B. Scalding C. Exposure to organic compounds D. Ionizing radiation
Answer: B Rationale: Thermal burns can be the result of a flash, scald, or contact with hot objects or flames. Direct current is a one directional constant flow of electricity. Radiation burns are associated with the industrial use of ionizing radiation, nuclear accidents, and therapeutic radiation treatment.
A patient is admitted to the emergency room after sustaining an electrical burn with contact points to his right hand and left foot. The patient is being resuscitated with lactated Ringer's solution using the consensus formula. A urinary catheter was placed, and the nurse observes myoglobin in the urine along with a decrease in urine output. What is the most appropriate nursing action? A. Give the patient a normal saline fluid bolus. B. Notify the physician and anticipate increasing the intravenous fluid rate. C. Administer a diuretic. D. Continue monitoring the patient.
Answer: B Rationale: To prevent myoglobin from obstructing the renal tubules, the intravenous fluid rate needs to be increased.
The nurse recognizes that burns to which body areas meet the criteria for referral to a burn center because of the increased risk of functional changes? (Select all that apply.) A. Chest B. Perineum C. Elbows D. Face E. Hands
Answer: B, C, D, and E Rationale: According the American Burn Association, referral criteria to a burn center involves injuries to specific areas of the body including the face, hands, feet, genitalia, perineum and burns over major joints. Burns in these locations involve functional areas of the body and may require specialized and highly skilled intervention in order to restore optimal function.
A 25-year-old male presents to the emergency room with a chemical burn to his hand. What is the nurse's first intervention? A. Delay treatment until the chemical is able to be identified. B. Elevate the extremity to promote circulation. C. Protect yourself, remove the patient's clothing, and begin irrigation with copious amounts of water. D. Contact The Poison Control Center to determine the most appropriate neutralizing agent.
Answer: C Rationale: Personal safety is always first priority, followed by irrigation with water
The nurse correlates which clinical manifestation to superficial partial-thickness burns? A. Eschar B. Dry, leathery appearance C. Blisters D. Waxy appearance
Answer: C Rationale: Superficial partial thickness burns often have wet, weeping blisters and are pink in color. Deep partial thickness burns appear waxy and do not have the characteristic weeping blisters that are seen in superficial partial thickness injuries. Full thickness burns generally have no blister formation, and are always very dry and feel like leather to the touch.
A patient weighing 100 kg sustains a burn at 1400 covering approximately 50% TBSA. The patient is a young healthy male with no medical history. Using the Parkland formula, how much fluid should be infused by 1800? A. 20,000 ml lactated Ringer's B. 10,000 ml lactated Ringer's C. 5,000 ml lactated Ringer's D. 2,000 ml lactated Ringer's
Answer: C Rationale: The Parkland formula is 4 ml x 100 kg x 50% TBSA = 20,000 ml. Half of this amount (10,000ml) needs to be given in the first 8 hours therefore half that amount (5,000ml) needs to be given within the first 4 hours of resuscitation.
Several clients have been brought to the emergency department after an office building fire. Which client is at greatest risk for inhalation injury? A) Middle-aged adult who is frantically explaining to the nurse what happened B) Young adult who suffered burn injuries in a closed space C) Adult with burns to the extremities D) Older adult with thick, tan-colored sputum
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. Clients who experienced a fire typically have some type of respiratory distress. However, the client talking without difficulty demonstrates 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.
Which clinical manifestation is indicative of wound healing for a 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
C Indicators of wound healing include the presence of granulation, re-epithelialization, and scar tissue formation. Pale, boggy, dry, or crusted granulation tissue is indicative of infection, as are increasing wound drainage and sloughing of grafts.
A client with burn injuries is being admitted. Which priority does the nurse anticipate within the first 24 hours? A) Range-of-motion exercises B) Emotional support C) Fluid resuscitation D) Sterile dressing changes
C The client will require fluid resuscitation because fluid does not stay in the vessels after a burn injury. Range-of-motion exercise is not the priority for this client. Although emotional support and sterile dressing changes are important, they are not the priority during the resuscitation phase of burn injury.
Which assessment is the nurse's highest priority in caring for a client in the acute phase of burn injury? A) Bowel sounds B) Muscle strength C) Signs of infection D) Urine output
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. Assessing bowel sounds, assessing muscle strength, and assessing urine output are important but not the priority during the acute phase of burn injury.
A client is in the acute phase of burn injury. For which action does the nurse decide to coordinate with the registered dietitian? A) Discouraging having food brought in from the client's favorite restaurant B) Providing more palatable choices for the client C) Helping the client lose weight D) Planning additions to the standard nutritional pattern
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. 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.
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) Administer a diuretic. B) Provide a fluid bolus. C) Recalculate fluid replacement based on time of hospital arrival. D) Titrate fluid replacement.
D 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. Giving a diuretic will 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.
