EAQs Burns Chap 25

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? 1. Intravenous (IV) morphine sulfate 2. Subcutaneous (SQ) tetanus toxoid 3. Intramuscular (IM) hydromorphone 4. Oral (PO) oxycodone and acetaminophen

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

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

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

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

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? Monitor for signs of complications Assess and manage pain and anxiety Discuss possible reconstructive surgery Begin intravenous (IV) fluid replacement

Monitor for signs of complications. 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.

While caring for a patient with burns, a nurse wraps the patient's wound with tubular elastic gauze. What are the reasons behind this action? 1. To decrease pain 2. To prevent blistering 3. To decrease itchiness 4. To reduce venous return 5. To enhance local immunity

1, 2, 3 The interim pressure due to tubular elastic gauze decreases pain and itchiness and prevents blistering. It promotes venous return rather than reducing it. It does not enhance local immunity.

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

1, 2, 3, 5 A patient who is intubated and has suffered burns to more than 5% of the body surface area may need gastric feedings to meet adequate nutritional requirements. Early enteral feeding helps to preserve gastrointestinal function, increase intestinal blood flow, and promote optimal conditions for wound healing. The nurse should check the placement of the nasogastric tube and assess bowel sounds every eight hours. The enteral feedings should be started at 20 to 40 mL/hr and slowly increased to the goal rate within 24 to 48 hours. Gastric residuals should be checked to rule out delayed gastric emptying.

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

1, 2, 5 Within 6 to 12 hours after the burn injury in which smoke inhalation is suspected, a fiberoptic bronchoscopy should be performed to assess the lower airway. Reposition the patient every one to two hours, and provide suctioning and chest physiotherapy, as prescribed, to clear the airway. Encourage deep breathing and coughing every hour to clear the air passages and provide relief to the patient. When intubation is not performed, the treatment of inhalation injury includes administration of 100% humidified O 2 as needed. Place the patient in a high-Fowler's position, unless contraindicated, as in spinal injury, and encourage deep breathing and coughing every hour.

A patient with partial-thickness burns is being treated with zolpidem. What is the appropriate nursing response to the patient's caregivers when they ask about the purpose of administering this drug? 1. To promote sleep 2. To reduce anxiety 3. To promote wound healing 4. To prevent thromboembolism 5. To provide short-term amnesic effects

1, 2, 5 Zolpidem is a sedative-hypnotic medicine and is given to patients suffering from burns. Zolpidem promotes sleep, reduces anxiety, and provides short-term amnesic effects. Nutritional support is used to promote wound healing. Anticoagulants are used to prevent thromboembolism.

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

1, 3, 4 Eye care for corneal burns or edema includes antibiotic ointments. An ophthalmology examination should be conducted on all patients who have sustained facial burns. The use of methylcellulose drops or artificial tears is recommended for moisture and additional comfort. Waiting for laboratory reports does not help the patient; rather, the nurse can start the basic examination and treatment in the process mentioned above. Avoid giving any misleading information, such as telling the patient that periorbital edema is serious. This can frighten the patient and prevent eye opening. The nurse should assure the patient that the swelling is not permanent.

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? 1, Escharotomy 2. Administration of diuretics 3. Daily cleansing and debridement 4. Application of topical antimicrobial agent 5. Intravenous (IV) and oral pain medications

1, 3, 4, 5 Pain control is essential in the care of a patient with a burn injury. Daily cleansing and debridement, as well as application of an antimicrobial ointment, are expected interventions used to minimize infection and enhance wound healing. An escharotomy (a scalpel incision through full-thickness eschar) frequently is required to restore circulation to compromised extremities. With full-thickness burns, myoglobin and hemoglobin released into the bloodstream can occlude renal tubules. Adequate fluid replacement is used to prevent this occlusion.

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

1, 3, 5 Begin fluid replacement to compensate for fluid loss. Cover the burned areas with dry dressings to begin the healing process and thus prevent contamination. An intravenous access should be established with two large-bore catheters to enable large amounts of fluid replacements. Supplemental oxygen is required to maintain adequate perfusion. The injured limb should be kept elevated above the heart level to prevent and decrease swelling.

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

1, 3, 5 Restlessness can result from respiratory distress, because the patient experiences disturbances in breathing. Increased agitation could result from the patient's attempts to compensate for an increasing oxygen demand and can be a sign of respiratory distress. An increased respiratory rate is a compensatory mechanism for the increased oxygen demands. It is a sign of impending respiratory distress and needs immediate attention. Increased sleep does not result from respiratory distress, because the patient becomes restless. Increased water intake is not specific to respiratory distress.

A burn patient is about to receive a dressing change. The patient has dressings over both feet and lower legs and is receiving a continuous infusion of hydromorphone (Dilaudid). Which medication(s) is/are appropriate for the patient to receive before the dressing change is started? Select all that apply. 1. Lorazepam (Ativan), an anxiolytic 2. Slow-release oral morphine (MS Contin) 3. Zolpidem (Ambien), a sleep-inducing hypnotic 4. Intravenous fentanyl (Sublimaze), a short-acting opioid 5. The patient will not need additional medication because the patient is receiving a continuous opioid infusion.

1, 4 Burn patients experience two kinds of pain: (1) continuous, background pain that might be present throughout the day and night; and (2) treatment-induced pain associated with dressing changes, ambulation, and rehabilitation activities. With background pain, a continuous intravenous (IV) infusion of an opioid (e.g., hydromorphone) allows for a steady, therapeutic level of medication. For treatment-induced pain, premedicate with an analgesic and an anxiolytic via the IV or oral route. For patients with an IV infusion, a potent, short-acting analgesic, such as fentanyl, often is effective. If an IV infusion is not present, slow-release, twice-a-day opioid medications (e.g., morphine) are indicated. The morphine would not be appropriate for this patient as the patient is receiving an IV pain medication infusion. A sleeping pill is not appropriate at this time. Text Reference - p. 463

A nurse plans to provide an antioxidant regimen for a patient with partial-thickness burns in the acute phase. Which are antioxidants and therefore should be included in the protocol? 1. Zinc 2. Water 3. Calcium 4. Selenium 5. Multivitamins

1, 4, 5 Zinc is an antioxidant and also a part of the antioxidant protocol because it supports cell growth and development. Selenium is used in the antioxidant protocol, because it helps to prevent cell damage. Multivitamins are a part of the antioxidant protocol because they help to compensate for the nutritional deficiencies of essential vitamins and minerals. Water is useful for the patient but does not form a part of the antioxidant protocol. Calcium is important to maintain strong bones and teeth, but it is not included in the antioxidant protocol. p. 446

As per the Parkland (Baxter) formula, the estimated total fluid requirement in the first 24 hours for a severely burned patient who weighs 80 kg and when more than 40% of the total body surface area (TBSA) is burned should be _________ mL. Record your answer using a whole number and no punctuation.

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

A nurse is teaching a group of parents how to reduce the risk for injury related to burns. Which statement by a participant indicates effective learning? "Frayed wires are OK to use at home." "I should hold regular home fire exit drills." "I should use gasoline with care to start a fire." "I should perform outdoor activities with caution during electrical storms."

2

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

2

The nurse is providing education to a patient who is in the rehabilitation phase of burn recovery after burning the arm with scalding water. Which of these statements by the patient indicates a need for further instruction? 1. "If the area itches, I can apply a water-based moisturizer." 2. "After a month, I will be able to go to the beach to get a tan." 3. "I will need to wear the pressure garment for 24 hours a day." 4. "I will continue the range-of-motion exercises on a regular schedule."

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

A 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? 1. The total 24-hour fluid requirement should be administered in the first 8 hours. 2. One-half of the total 24-hour fluid requirement should be administered in the first 8 hours. 3. One-third of the total 24-hour fluid requirement should be administered in the first 4 hours. 4. One-half of the total 24-hour fluid requirement should be administered in the first 4 hours.

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

A nurse working in a burn unit identifies that which patients are at an increased risk of developing venous thromboembolism? Young age Morbid obesity Prolonged immobility Upper-extremity burns First-degree burn of a finger

2, 3 The risk factors for the development of venous thromboembolism a burn patient are morbid obesity and prolonged immobility. These patients may develop stasis of blood due to immobility, which results in development of venous thromboembolism. Young age is not a risk factor for venous thromboembolism; rather, old age predisposes a person to venous thromboembolism. Usually lower-extremity burns are risk factors for venous thromboembolism, because they cause stagnation of blood. First-degree burn of a finger is not an extensive burn and hence not a risk factor for venous thromboembolism.

When teaching patients and caregivers about the strategies to reduce burn injuries, what essential instructions does the nurse give? 1. Perform outdoor activities during lightning storms. 2. Never leave burning candles unattended or near windows or curtains. 3. Ensure an electrical power source is shut off before beginning repairs. 4. Check temperature of bath water with the back of hand or bath thermometer. 5. Store chemicals in the lowest shelves to avoid mixing up with other household chemicals.

2, 3, 4 Ensure that the electrical power source is shut off before beginning any repairs to avoid electrical burn injury. Never leave candles unattended or near open windows or curtains to avoid fire. Check the temperature of the bath water using the back of the hand or use the bath thermometer to avoid scalding burns, which commonly occur due to hot bathing water. Chemicals should be stored safely, preferably out of reach of children, in clearly written labels. Performing outdoor activities during lightning storms increases the risk of electrical injury from the ongoing lightning. p. 430

Which precautions should the nurse take when changing a burn wound dressing? 1. Use sterile gloves when removing a contaminated dressing. 2. Use sterile gloves when applying ointments and sterile dressings. 3. Wear nonsterile, disposable gloves when washing the dirty wound. 4. Keep the room cool to decrease the burning sensation of the wound. 5. Always wear personal protective equipment, such as masks, gowns, and gloves.

2, 3, 5 The nurse should use sterile gloves when applying ointment and sterile dressings. Nonsterile, disposable gloves should be worn when removing contaminated dressings and washing a dirty wound. The nurse should always wear personal protective equipment before the burn wounds are exposed. The room should be kept warm to prevent shivering in the patient.

A nurse is providing care to a patient who presents with a scald burn injury. When assessing this patient, which clinical manifestations should the nurse anticipate? Blanching Severe pain White, waxy skin Red, shiny vesicles Mild to moderate edema

2, 4, 5 Scald burn injuries cause second-degree burns. Clinical manifestations of second-degree burns include severe pain, the appearance of fluid-filled vesicles, the appearance of "shiny" skin, and mild to moderate edema. Blanching is observed in first-degree burns, and white, waxy skin is seen in third- and fourth-degree burns.

A patient with partial-thickness burns is now allowed oral feedings. What nursing interventions should the nurse perform to maintain the patient's nutrition? 1. Suggest low-calorie food. 2. Suggest a high-protein diet. 3. Suggest reduced fluid intake. 4. Suggest a high-carbohydrate diet. 5. Ask caregivers to get the patient's favorite food.

2, 4, 5 The patient may have a reduced appetite and may not like the food from the hospital. Therefore the caregivers can get the patient's favorite food. A swallowing assessment should be done by a speech pathologist before beginning with oral feeds. The patient should be provided with a high-protein diet to promote tissue healing and avoid malnutrition. A high-carbohydrate diet should be provided to meet the high metabolic demands. A low-calorie food may not meet the calorie requirements of the patient and leads to malnutrition and delayed wound healing. An adequate intake of fluids is essential for healing. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.

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

2, 4, 5 The nurse should assess bowel sounds every eight hours to ensure proper functioning of the bowels before starting oral nutrition. The nurse should also begin early enteral feeding with smaller-bore tubes, because this preserves gastrointestinal (GI) function, increases intestinal blood flow, and promotes optimal conditions for wound healing. The feedings should begin slowly at a rate of 20 to 40 mL/hr to protect the GI function and gradually increase as the patient improves. Assessing the respiratory rate every two hours is not related to nutritional therapy. Large amounts of feeding within the first six hours may overload the system and affect the GI function.

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

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

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

3 Hot water heaters set at 140° F (60° C) or higher are a burn hazard in the home; the temperature should be set at less than 120° F (40° C). A risk-reduction strategy for household fires is to encourage regular home fire exit drills. Gasoline or other flammable liquids should never be used to start a fire. Installation of smoke and carbon monoxide detectors can prevent inhalation injuries. Hard-wired smoke detectors do not require battery replacement; battery-operated smoke detectors may be used.

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

3 In the rehabilitation phase, the patient will work toward resuming a functional role in society, but frequently there are body image concerns and grieving for the loss of the way the body looked and functioned before the burn, so continued counseling helps the patient in this phase as well. Putting the leg in the position of comfort is more likely to lead to contractures than to help the patient. If a pressure garment is prescribed, it is used for 24 hours per day for as long as 12 to 18 months. Sunlight should be avoided to prevent injury and sunscreen should always be worn when the patient is outside.

A patient has thermal burns on the face, including the cheeks and the area around the eyes. Which measures should the nurse take? Instill artificial tears in each eye. Wrap sterile gauze around his face. Cover the face with silver sulfadiazine ointment and gauze. Apply silver sulfadiazine ointment only without the use of gauze.

3 The face is highly vascular and may become edematous after a thermal burn. It should be covered with ointment and gauze to prevent vascularization and swelling. Wrapping gauze around the face will create pressure on delicate facial structures. The gauze is required to cover the face after the application of silver sulfadiazine ointments to prevent infection. Artificial tears or methylcellulose drops are used to treat eyes after a burn.

What are the clinical manifestations of a lower airway lung injury associated with burns? Edema Blisters Dyspnea Wheezing Altered mental status

3, 4, 5

While treating a patient who is administered initial emergency burn care and is in the acute phase of burns, what actions should the nurse perform as a part of respiratory therapy? Select all that apply. 1.Avoid supplemental oxygen. 2. Prepare for discharge home. 3. Monitor for signs of complications. 4. Continue assessing oxygenation needs. 5. Continue to monitor respiratory status.

3,4,5 The nurse should monitor for signs of respiratory complications of burns to plan for appropriate respiratory therapy. Continue assessing oxygenation needs to plan for any alternations in oxygen supply. Continue to monitor the respiratory status to ensure proper breathing and circulation. Avoiding supplemental oxygen is not advisable, as oxygen needs may be assessed and started as required. Preparing for discharging the patient needs to be planned in the rehabilitation phase after the patient has recovered.

A patient presents in the emergency department (ED) with burns on the hands and face after handling hydrochloric acid at work. What actions should the nurse perform toward the patient's burn management? 1. Apply ice to the burned area. 2. Never wash the burn with water. 3. Flush affected area with lots of water. 4. Remove all chemical particles on skin. 5. Remove all clothing containing the chemical.

3. 4. 5 Remove all chemical particles on skin to remove the burn-causing agent from the patient's body. Remove all clothing containing the chemical, because the burning process continues while the chemical is in contact with the skin. Flush affected area with copious amounts of water to irrigate the skin from 20 minutes to two hours after chemical exposure to clear off the chemical on or around the affected area. Applying ice to the burned area does not help to wash away the chemical. Washing the burnt area with water helps to clean off the chemical.

A burn patient has not received any active tetanus immunization within the previous 12 years. What is the primary nursing measure to help prevent the development of tetanus in the patient? 1. Administer tetanus toxoid 2. Provide musculoskeletal relaxants 3. Provide 100% oxygen to the patient 4. Administer tetanus immunoglobulin

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

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? Serum sodium and potassium increase Serum sodium and potassium decrease Edema and arterial blood gases improve Diuresis occurs and hematocrit decreases

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

Anticipate the need for endotracheal intubation and notify the health care provider Inhalation injury results from exposure of the respiratory tract to intense heat or flames with inhalation of noxious chemicals, smoke, or carbon monoxide. The nurse should anticipate the need for endotracheal intubation and mechanical ventilation, because this patient is demonstrating signs of severe respiratory distress. The nurse should also obtain vital signs and ABGs and insert a Foley, but these interventions are not a priority at this time. A sputum sample is not necessary at this time. Test-Taking Tip: Answer every question because, on the NCLEX exam, you must answer a question before you can move on to the next question.

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

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

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

Tachycardia Albuterol stimulates beta 2 receptors in the lungs to cause bronchodilation. However, it is a non-cardioselective agent so it also stimulates the beta 2 receptors in the heart to increase the heart rate. Restlessness and GI upset may occur, but will decrease with use. Hypokalemia does not occur with albuterol.

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

to prevent blood clots A patient with severe burns is at greater risk of venous thromboembolism. Omega-3 fatty acids are natural anticoagulants that decrease platelet aggregation. Eating foods rich in tryptophan, not omega-3 fatty acids, improves the patient's sleeping pattern. Tryptophan is an amino acid that blocks body wakeup cycles and promotes sleep. Foods rich in protein and fats, like peanut butter and red meat, help the patient gain weight. Avoiding spicy foods and drinking plenty of pure water helps decrease stomach acid. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.