Lewis Chapter 25: Burns, CH 57 BURNS, Chapter 46: Burns: Nursing Management, Medical Surgical Nursing Chapter 12 Inflammation and Wound Healing, Lewis Ch. 22 - Assessment of Integumentary System, Lewis 10th Chapter 22 Assessment of Integumentary Syst...

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A nurse is examining the pressure ulcer of a patient and observes that subcutaneous fat is visible in the ulcer, but bones, muscle, and tendon are not visible. Slough is present and there is tunneling of the ulcer. From this observation, what stage of the ulcer should the nurse record in the patient's medical record? 1 Stage II 2 Stage III 3 Stage IV 4 Unstageable

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 The types of burn injuries that should be referred to a burn unit for care include burns to the face and genitalia; burns to a fractured limb; and burns caused by chemicals. Sunburn and a small burn from hot water do not need to be referred to a burn unit for care.

1, 2, 4

A nurse is caring for a patient who is receiving negative-pressure wound therapy. Which parameters should be monitored for a patient on negative-pressure wound therapy? Select all that apply. 1 Platelet count 2 Prothrombin time 3 Serum creatinine level 4 Partial prothrombin time 5 Fasting blood glucose level

1, 2, 5 Deficiency of zinc impairs epithelialization, delaying the wound healing process. Protein deficiency decreases the supply of amino acids available for tissue repair. Deficiency of vitamin C delays formation of collagen fibers and capillary development. Sodium and copper are not strongly related to wound healing. Text Reference - p. 183

A nurse is explaining to a patient about the common nutritional deficiencies that cause delayed wound healing. Which are the most common elements whose deficiency delays wound healing? Select all that apply. 1 Zinc 2 Protein 3 Sodium 4 Copper 5 Vitamin C

1 The complement system causes cell lysis by creating holes in the cell membranes, causing those cells to rupture. The complement system increases vascular permeability. Thromboxane promotes clot formation during healing. Macrophages clean the injured area before healing. Text Reference - p. 174

What is the function of the complement system during an immune response? 1 Cellular lysis 2 Promoting clot formation 3 Decrease in vascular permeability 4 Cleaning the injured area before healing

4 A turning schedule including proper documentation is the best way to ensure that the patient is repositioned every one to two hours. Sliding instead of lifting the patient causes friction and may result in skin tears. Placing a patient on a doughnut ring is contraindicated because it results in an area of pressure; three to four hours is too long between changes of position. Lotion applied to the skin does provide moisture, but vigorous massage may cause tissue damage. Text Reference - p. 187

Which nursing intervention should be included on a plan of care to prevent the development of pressure ulcers in a bedridden patient? 1 Sliding the patient instead of lifting when turning 2 Repositioning the patient on a doughnut ring every three to four hours 3 Applying lotion after the patient bathes and vigorously massaging the skin 4 Implementing a turning schedule calling for position changes every one to two hours

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

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

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

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

A patient with hypothyroidism has developed carotenemia. The nurse should assess for improvement of this condition on which part of the patient's body? a. Face b. Chest c. Sclera d. Palms of hands

d. Palms of hands Carotenemia or carotenosis is yellow discoloration of the skin without yellowing sclera. It is most noticeable on the palms of the hands and the soles of the feet.

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

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

When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the skin is dry, pale, hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth? a. First-degree skin destruction b. Full-thickness skin destruction c. Deep partial-thickness skin destruction d. Superficial partial-thickness skin destruction

ANS: B With full-thickness skin destruction, the appearance is pale and dry or leathery and the area is painless because of the associated nerve destruction. Erythema, swelling, and blisters point to a deep partial-thickness burn. With superficial partial-thickness burns, the area is red, but no blisters are present. First-degree burns exhibit erythema, blanching, and pain

A patient in the dermatology clinic is scheduled for removal of a 15-mm multicolored and irregular mole from the upper back. The nurse should prepare the patient for which type of biopsy? a. Shave biopsy b. Punch biopsy c. Incisional biopsy d. Excisional biopsy

ANS: C An incisional biopsy would remove the entire mole and the tissue borders. The appearance of the mole indicates that it may be malignant. A shave biopsy would not remove the entire mole. The mole is too large to be removed with punch biopsy. Excisional biopsies are done for smaller lesions and where a good cosmetic effect is desired, such as on the face

17. A patient arrives in the emergency department after being burned in a house fire. The patient's burns cover the face and the left forearm. What percentage of burn does the patient have? A) 10% B) 25% C) 9% D) 18%

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

The nurse is assessing a client's burn for the zones of injury. Which of the following will the nurse not assess in the client at this time? 1. Zone of coagulation 2. Zone of eschar 3. Zone of hyperemia 4. Zone of stasis

2. Zone of eschar There is no zone of eschar. The zones of injury are the zone of coagulation, the zone of stasis, and the zone of hyperemia.

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

4. stabilization period. The three periods of treatment in the care of the seriously burned client are the emergent period, the acute period, and the rehabilitation period. There is no stabilization period of burn care.

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

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

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

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

4. The patient you are caring for has an electrical burn and has developed thick eschar over the burn wound. Which of the following topical antibacterial agents will the nurse expect the physician to order for the wound? A) Silver sulfadiazine 1% (Silvadene) water-soluble cream B) Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream C) Silver nitrate 0.5% aqueous solution D) Acticoat

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

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

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

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

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

7, 5, 8, 3, 1, 6, 4, 2 During the initial phase of wound healing, which is during the first three to five days, there is approximation of wound edges. Next, epithelial cells migrate to the site and clots form, serving as a meshwork for starting capillary growth. After the initial phase, the granulation phase starts, which lasts from five days to four weeks. It includes migration of fibroblasts at the site, secretion of collagen, and an abundance of capillary buds at the site. This makes the wound fragile. The next phase is the maturation and scar contraction phase, which includes remodeling of collagen and strengthening of the scar. This may last from seven days to several months, depending on wound size. Text Reference - p. 177

The nurse recalls that a surgical wound heals by primary intention. What is the order of the phases of primary intention healing? 1. Secretion of collagen 2. Strengthening of scar 3. Migration of fibroblasts 4. Remodeling of collagen 5. Migration of epithelial cells 6. Abundance of capillary buds 7. Approximation of incision edges 8. Clot serving as meshwork for starting capillary growth

2 Turning and repositioning the patient every one to two hours will keep pressure areas from developing and help prevent other pulmonary and vascular complications. Repositioning the patient every half hour is unrealistic. Keeping the patient supine as much as possible does not support the turning schedule. Turning the patient from one side to the other every four to eight hours is too much time between turning and repositioning. Text Reference - p. 188

To prevent complications, what turning schedule should the nurse implement for a patient who spends most of the day in bed? 1 Repositioning the patient every half hour 2 Repositioning the patient every one to two hours 3 Keeping the patient supine as much as possible 4 Turning the patient from one side to the other once every four to eight hours

1, 2, 5 Inflammation increases the permeability of the blood vessels by causing vasodilation, resulting in redness at the site. Inflammation causes a shifting of fluids to the interstitial spaces and fluid accumulation, resulting in swelling at the site. Swelling and pain can result in loss of cellular function at the inflammatory site. Characteristic odor and purulent exudate at the site are signs of infection. Text Reference - p. 173

What are the symptoms of inflammation at an injury site? Select all that apply. 1 Swelling at the site 2 Redness at the site 3 Characteristic odor at the site 4 Purulent exudate from the site 5 Loss of function of cells at the site

3 Prednisone is an antiinflammatory drug that interferes with tissue granulation and induces immunosuppressive effects; thus, this drug prevents the liberation of lysosomes. Ibuprofen inhibits the synthesis of prostaglandins. Piroxicam is an antiinflammatory drug that inhibits the synthesis of prostaglandins. Acetaminophen is an antipyretic drug that lowers body temperature by acting on the heat-regulating center in the hypothalamus. Text Reference - p. 176

Which drug prevents the liberation of lysosomes? 1 Ibuprofen 2 Piroxicam 3 Prednisone 4 Acetaminophen

1 The release of cytokines initiates metabolic changes in the temperature-regulating center of the hypothalamus. Thus, cytokines trigger fever during inflammation. Serotonin stimulates smooth muscle contraction. Bradykinin causes vasodilation and contraction of smooth muscle. Leukotriene stimulates chemotaxis. Text Reference - p. 174

Which inflammatory mediator may trigger fever during inflammation? 1 Cytokines 2 Serotonin 3 Bradykinin 4 Leukotrienes

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

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

A nurse is caring for a patient who has a pressure ulcer that is treated with debridement, irrigations, and moist gauze dressings. How should the nurse anticipate healing to occur? a. Tertiary intention b. Secondary intention c. Regeneration of cells d. Remodeling of tissues

b. Secondary intention

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

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

The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which of the following would provide the most reliable indicator for determining the adequacy? a. vital signs b. urine output c. mental status d. peripheral pulses

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

The unlicensed assistive personnel (UAP) is assisting the patient with Crohn's disease with perineal care. The UAP tells the nurse that the patient had feces coming from the vagina. What should the nurse do about this situation? a) Notify the health care provider. b) Document the fistula formation. c) Assess the patient and vaginal drainage. d) Have the UAP apply a dressing to the vagina.

c) Assess the patient and vaginal drainage. With Crohn's disease, a fistula may have formed between the bowel and the vagina. The nurse should first assess the patient and the drainage from the vagina. Then the nurse should notify the health care provider, document the occurrence and cares prescribed, provide cares prescribed, and document the care and patient response.

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

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

An emergency department nurse learns from the paramedics that they are transporting a patient who has suffered injury from a scald from a hot kettle. What variables will the nurse consider when determining the depth of burn? A) The causative agent B) The patient's preinjury health status C) The patient's prognosis for recovery D) The circumstances of the accident

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

A patient experienced a 33% TBSA burn 72 hours ago. The nurse observes that the patient's hourly urine output has been steadily increasing over the past 24 hours. How should the nurse best respond to this finding? A) Obtain an order to reduce the rate of the patient's IV fluid infusion. B) Report the patient's early signs of acute kidney injury (AKI). C) Recognize that the patient is experiencing an expected onset of diuresis. D) Administer sodium chloride as ordered to compensate for this fluid loss.

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

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

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

A patient with a partial-thickness burn injury had Biobrane applied 2 weeks ago. The nurse notices that the Biobrane is separating from the burn wound. What is the nurse's most appropriate intervention? A) Reinforce the Biobrane dressing with another piece of Biobrane. B) Remove the Biobrane dressing and apply a new dressing. C) Trim away the separated Biobrane. D) Notify the physician for further emergency-related orders.

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

The nurse caring for a patient who is recovering from full-thickness burns is aware of the patient's risk for contracture and hypertrophic scarring. How can the nurse best mitigate this risk? A) Apply skin emollients as ordered after granulation has occurred. B) Keep injured areas immobilized whenever possible to promote healing. C) Administer oral or IV corticosteroids as ordered. D) Encourage physical activity and range of motion exercises.

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

A patient is brought to the ED by paramedics, who report that the patient has partial-thickness burns on the chest and legs. The patient has also suffered smoke inhalation. What is the priority in the care of a patient who has been burned and suffered smoke inhalation? A) Pain B) Fluid balance C) Anxiety and fear D) Airway management

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

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 A full-thickness burn is a third-degree burn. A third-degree burn exhibits charred vessels visible under eschar, and the nerve endings are dead. There is no pain, and blisters are rare and do not increase in size. There is no blanching with pressure. Edema is not present with this type of burn injury.

16. A patient is brought to the ED by paramedics who report the patient has partial-thickness burns on the chest and legs. The patient has also suffered smoke inhalation. What is a priority in the care of a patient who has been burned and suffered smoke inhalation? A) Pain B) Fluid balance C) Anxiety and fear D) Airway management

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

In which order will the nurse take these actions when doing a dressing change for a partial-thickness burn wound on a patient's chest? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Apply sterile gauze dressing. b. Document wound appearance. c. Apply silver sulfadiazine cream. d. Administer IV fentanyl (Sublimaze). e. Clean wound with saline-soaked gauze

ANS: D, E, C, A, B Because partial-thickness burns are very painful, the nurse's first action should be to administer pain medications. The wound will then be cleaned, antibacterial cream applied, and covered with a new sterile dressing. The last action should be to document the appearance of the wound.

A dark-skinned patient has been admitted to the hospital with chronic heart failure. How would the nurse best assess this patient for cyanosis? a. Assess the skin color of the earlobes. b. Apply pressure to the palms of the hands. c. Check the lips and oral mucous membranes. d. Examine capillary refill time of the nail beds.

ANS: C Cyanosis in dark-skinned individuals is more easily seen in the mucous membranes. Earlobe color may change in light-skinned individuals, but this change in skin color is difficult to detect on darker skin. Application of pressure to the palms of the hands and nail bed assessment would check for adequate circulation but not for skin color

The nurse prepares to obtain a culture from a patient who has a possible fungal infection on the foot. Which items should the nurse gather for this procedure? a. Sterile gloves b. Patch test instruments c. Cotton-tipped applicators d. Local anesthetic, syringe, and intradermal needle

ANS: C Fungal cultures are obtained by swabbing the affected area of the skin with cotton-tipped applicators. Sterile gloves are not needed because it is not a sterile procedure. Local injection is not needed because the swabbing is not usually painful. The patch test is done to determine whether a patient is allergic to specific testing material, not for obtaining fungal specimens

Which abnormality on the skin of an older patient is the priority to discuss immediately with the health care provider? a. Several dry, scaly patches on the face b. Numerous varicosities noted on both legs c. Dilation of small blood vessels on the face d. Petechiae present on the chest and abdomen

ANS: D Petechiae are caused by pinpoint hemorrhages and are associated with a variety of serious disorders such as meningitis and coagulopathies. The nurse should contact the patient's health care provider about this finding for further diagnostic follow-up. The other skin changes are associated with aging. Although the other changes will also require ongoing monitoring or intervention by the nurse, they do not indicate a need for urgent action

During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion? a. Check skin turgor. b. Monitor daily weight. c. Assess mucous membranes. d. Measure hourly urine output.

ANS: D When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hour. The patient's weight is not useful in this situation because of the effects of third spacing and evaporative fluid loss. Mucous membrane assessment and skin turgor also may be used, but they are not as adequate in determining that fluid infusions are maintaining adequate perfusion.

A nurse who provides care on a burn unit is preparing to apply a patient's ordered topical antibiotic ointment. What action should the nurse perform when administering this medication? A) Apply the new ointment without disturbing the existing layer of ointment. B) Apply the ointment using a sterile tongue depressor. C) Apply a layer of ointment approximately 1/16 inch thick. D) Gently irrigate the wound bed after applying the antibiotic ointment.

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

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

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

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

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

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

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

9. A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. What would be the nurse's priority concern about this patient? A) Fluid status B) Risk of infection C) Body image D) Level of pain

FLUID STATUS **During the early phase of burn care, the nurse is most concerned with fluid resuscitation, to correct large-volume fluid loss through the damaged skin. Infection, body image, and pain are significant areas of concern, but are less urgent than fluid status.

1, 2, 6 Skin, bone marrow, and mucous membranes have labile cells that divide constantly. Injury to these organs is followed by rapid regeneration. Pancreas and kidney have stable cells that retain their ability to regenerate only if the organ is injured; the regeneration is slow. Cardiac muscle cells are permanent cells that do not divide; healing occurs by repair with scar tissue. Text Reference - p. 177

The nurse is dressing a laceration on the palmar aspect of the hand on the patient. Which tissues have labile cells that regenerate rapidly? Select all that apply. 1 Skin 2 Bone marrow 3 Pancreas 4 Cardiac muscle cells 5 Kidney 6 Mucous membranes

3 Stage III pressure ulcers are defined as full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. Stage I ulcers have intact skin with nonblanchable redness of a local area with a change in skin temperature, tissue consistency, or sensation. Stage II ulcers are partial-thickness with a red-pink wound bed. Stage IV ulcers involve extensive destruction of tissue with exposed bone, tendon, or muscle. Text Reference - p. 185

The patient is admitted with a pressure ulcer with full-thickness skin loss involving damage to subcutaneous tissue. How should the nurse document it? 1 Stage I 2 Stage II 3 Stage III 4 Stage IV

5. The occupational health nurse is called to the floor of the factory where a patient has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to "cool the burn." How will the nurse cool the burn? A) Apply ice to the site of the burn for 5 to 10 minutes. B) Wrap the patient's affected extremity in ice until help arrives. C) Apply an oil-based substance or butter to the burned area until help arrives. D) Wrap cool towels around the affected extremity intermittently.

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

4 Lymphocytes stimulate cell-mediated immunity by releasing various cytokines in response to an antigen at the injury site. Neutrophils arrive at the injury site first and engulf bacteria. A giant cell made of a group of macrophages forms a granuloma. Macrophages clean the injury site before healing by engulfing dead cells and foreign particles. Text Reference - p. 174

What is the primary role of lymphocytes? 1 Engulfing bacteria 2 Forming granuloma 3 Cleaning the area before healing 4 Stimulating cell-mediated immunity

2 Alginates form a nonsticky gel on contact with a draining wound. They are easy to use over irregularly shaped wounds and generally require a secondary dressing. Foams are sheets that hold large amounts of exudates and mostly require gauze wrapping. Hydrogels donate moisture to a dry wound and maintain a moist environment that rehydrates wound tissue. Semipermeable transparent films allow visualization of the wound and are minimally absorbent. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer. Text Reference - p. 182

Which type of wound dressing is easy to use over irregularly shaped wounds and forms a nonsticky gel on contact with a draining wound? 1 Foam 2 Alginate 3 Hydrogel 4 Semipermeable transparent film

Which strategy by the nurse would be most helpful in treating a patient who is experiencing chills because of an infection? a) Provide a light blanket. b) Encourage a hot shower. c) Monitor temperature every hour. d) Turn up the thermostat in the patient's room.

a) Provide a light blanket. Chills often occur in cycles and last for 10 to 30 minutes at a time. They usually signal the onset of a rise in temperature. For this reason, the nurse should provide a light blanket for comfort but avoid overheating the patient.

After the unlicensed assistive personnel (UAP) bathed the patient, she then told the nurse about a reddened area on the patient's coccyx. After assessing the area, what should the nurse have the UAP do for the patient? a) Reposition every 2 hours. b) Measure the size of the reddened area. c) Massage the area to increase blood flow. d) Evaluate the area later to see if it is better.

a) Reposition every 2 hours. The most important thing to do for this patient is to prevent deterioration of the ulcer and eliminate factors that led to pressure ulcers. This would include eliminating pressure on the reddened area with repositioning every 2 hours in bed and every hour while up in the chair. The nurse must complete the assessment of the new reddened area as well as evaluation of the area. Massage is not used when there is the possibility of damaged blood vessels or fragile skin so the RN cannot advise the UAP to do this until the RN has assessed the patient and the area.

The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third degree circumferential arm burn. The nurse understands that the anticipated therapeutic outcome of the escharotomy is: a. return of distal pulses b. brisk bleeding from the site c. decreasing edema formation d. formation of granulation tissue

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

An 85-year-old patient is assessed to have a score of 16 on the Braden Scale. Based on this information, how should the nurse plan for this patient's care? a. Implement a q2hr turning schedule with skin assessment. b. Place DuoDerm on the patient's sacrum to prevent breakdown c. Elevate the head of bed to 90 degrees when the patient is supine d. Continue with weekly skin assessments with no special precautions

a. Implement a q2hr turning schedule with skin assessment.

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

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

A patient has been provided with a compression dressing in an attempt to facilitate rapid healing of an ankle sprain. What is a priority nursing assessment? a) Frequent examination of the character and quantity of exudate b) Monitoring for signs and symptoms of local or systemic infections c) Assessment of the patient's circulation distal to the location of the dressing d) Assessment of the range of motion of the ankle and the patient's activity tolerance

c) Assessment of the patient's circulation distal to the location of the dressing Any compression dressing requires vigilant assessment of the circulation distal to the dressing site, since tissue and nerve damage is a significant risk. This supersedes the importance of assessing the patient's mobility. Exudate and infection would not normally accompany a soft tissue injury such as a sprain.

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

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

The nurse is caring for a patient with superficial partial-thickness burns of the face sustained within the last 12 hours. Upon assessment, the nurse would expect to find which of the following symptoms? A. Blisters B. Reddening of the skin C. Destruction of all skin layers D. Damage to sebaceous glands

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

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

b.

A victim of an industrial accident has chemical spilled on his face and body. The chemical, which has a pH of 7.51, is flushed with water by paramedics. What is the most important information for the receiving nurse to obtain about the pt from the paramedics? a. containment of chemical b. duration of water flushing c. other injuries of the victim d. specific location of accident

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

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

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

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 The emergent period is the first 24 to 48 hours after a burn. The acute phase begins after the emergent period ends and lasts until the burn is healed. The rehabilitation period begins with wound closure and continues until the patient has reached the highest level of functioning.

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 goals of management during the emergent period the first 24 to 48 hours after a burn are to secure the airway, support circulation by fluid replacement, keep the client comfortable with analgesics, prevent infection through careful wound care, maintain the body temperature, and provide emotional support. Rehabilitation of the client is not an immediate concern during the emergent period.

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 Notifying emergency management of a burn injury within 1 hour of occurrence is not a typical sign of abuse. The other options are typical signs of abuse.

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. Morphine sulfate is the drug of choice for pain relief for the client experiencing a burn. Acetaminophen and aspirin are not strong enough to control the pain for this client. Meperidine is not provided as the drug of choice.

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. Goals for initial wound care for a client newly diagnosed with a burn include cleansing to prevent infection, prevent further skin destruction, and provide comfort. Skin hydration and prevention of nutritional deficits are not goals of initial wound care.

An individual's 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 individual should not stand. Standing will cause the flames and smoke to engulf the facial area. The best intervention is to stop the person; wrap him in a blanket, coat, sheet, or towel; and roll him on the ground to exclude oxygen and thereby put out the fire. Any water source can be used to extinguish flames, cool the burn, or dilute the chemical area. Once all the flame is extinguished, clothing (except clothing adhered to burned skin), jewelry, and debris are carefully removed. The burned areas should be covered with a dry clean material.

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

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

The 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 Ringer's solution × body weight × percent burn. 2. 2 to 3 mL of lactated Ringer's solution × body weight × percent burn. 3. 2 to 4 mL of lactated Ringer's solution × body weight × percent burn. 4. 3 to 6 mL of lactated Ringer's solution × body weight × percent burn.

3. 2 to 4 mL of lactated Ringer's solution x body weight x percent burn. The formula used to calculate the volume of IV fluid required for fluid resuscitation is based on the Parkland formula. Using this formula, the client's fluid requirements for the first 24 hours after injury are estimated. For adults, the formula is 2 to 4 mL of lactated Ringer's solution × body weight (in kg) × percent burn. The other amounts of fluid are incorrect for the adult client.

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 client's burn as being: 1. 36%. 2. 45%. 3. 54%. 4. 63%.

3. 54%. The right and left arms are 18%, the back is 18%, and the posterior legs are 18%; this equals 54%. The other calculations are incorrect.

A client is recovering from a skin graft to her right arm. Which of the following nursing interventions would not be indicated for this client? 1. Assess for bleeding. 2. Assess for drainage underneath the graft site. 3. Encourage exercise of the right arm. 4. Remove dressings slowly.

3. Encourage exercise of the right arm. Exercise of the site may cause dislodgement of the skin graft. The graft should be examined every 24 hours because drainage or blood can accumulate under the graft and cause nonadherence. Dressings should be removed slowly and carefully so that the graft is not disturbed.

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 A heterograft (xenograft) is a graft of skin obtained from another species, such as a pig. An autograft is a permanent graft. A homograft, or cryopreserved cadaveric allograft, is a graft of skin obtained from a cadaver 6 to 24 hours after death that is used as a temporary graft. An allograft is a graft of skin from someone of the same species.

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 A second-degree burn is a partial-thickness burn. This type of burn is very painful, has blisters that increase in size, blanches with pressure, and may or may not require grafting. The other characteristics are for first- or third-degree burns.

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

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

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 A urine output of 30 to 50 mL per hour is a sign of adequate fluid hydration. A brassy cough, hoarseness, or an increasing respiratory rate can be signs of potential airway obstruction and respiratory distress.

To support the nutritional needs of a client recovering from a burn injury, the nurse will prepare to administer which of the following? 1. High carbohydrate diet 2. High fat diet 3. Low protein diet 4. Vitamins C and A supplements

4. Vitamins C and A supplements Vitamins C and A are provided at doses higher than recommended because of the role they play as cellular antioxidants, and they are required for collagen synthesis. A high carbohydrate diet should be avoided to prevent carbon dioxide production and hyperglycemia. Protein is needed for wound healing and should be calculated according to the client's weight. Fat intake should not exceed 30% of total daily calories.

An 80-kg patient with burns over 30% of total body surface area (TBSA) is admitted to the burn unit. Using the Parkland formula of 4 mL/kg/%TBSA, what is the IV infusion rate (mL/hour) for lactated Ringer's solution that the nurse will administer during the first 8 hours?

600 mL The Parkland formula states that patients should receive 4 mL/kg/%TBSA burned during the first 24 hours. Half of the total volume is given in the first 8 hours and then the last half is given over 16 hours: 4 80 30 = 9600 mL total volume; 9600/2 = 4800 mL in the first 8 hours; 4800 mL/8 hr = 600 mL/hr.

24. You have just reported to the burn unit to start your shift. Four new patients have been admitted in the past 12 hours. Which patient is most likely to have life-threatening complications? A) A 4-year-old scald victim burned over 24% of the body B) A 27-year-old healthy male burned over 36% of his body in a car accident C) A 39-year-old female with myasthenia gravis burned over 18% of her body D) A 60-year-old male burned over 16% of his body in a brush fire

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

3, 4, 5 The nurse should teach the patient's caregiver to provide the patient with adequate nutrition to speed up the healing process. Exposure to excessive moisture from incontinence can cause pressure ulcers. The caregiver should cleanse skin after soiling and use absorbent pads or briefs to help keep the patient dry. The patient should be assisted in lifting himself or herself when repositioning in bed because sliding can cause friction and sheer. A wheelchair-bound patient should be repositioned every hour, whereas a patient confined to bed should be repositioned every two hours. Text Reference - p. 187

A 65-year-old diabetic patient is treated for a fractured fibula and is discharged from the health care facility. Which instructions should the nurse give the patient's caregiver to prevent occurrence of pressure ulcers in the patient? Select all that apply. 1 Reposition the patient in wheelchair every two hours. 2 Reposition the patient in bed every six hours. 3 Provide the patient with adequate nutrition. 4 Provide the patient absorbent pads or briefs. 5 Assist the patient to lift self and reposition on bed.

2 Impaired tissue integrity would be a priority nursing diagnosis for this patient. Interventions to prevent further damage and other areas of impaired tissue would be essential. Acute pain, imbalanced nutrition, and risk for infection may be appropriate nursing diagnoses but are not a priority at this time. Text Reference - p. 186

A 75-year-old stroke patient with limited mobility and altered mental status has a black area of suspected deep tissue injury on the left greater trochanter. Which nursing diagnosis is most appropriate for this patient? 1 Acute pain related to tissue damage and inflammation. 2 Impaired tissue integrity related to inadequate circulation secondary to pressure. 3 Risk for infection related to loss of tissue integrity and undernutrition secondary to stroke. 4 Imbalanced nutrition: less than body requirements related to inability to consume sufficient calories and nutrients secondary to stroke.

1, 2, 5 Foam dressings, alginate dressings, and hydrocolloidal dressings are best suited for moderate to heavy drainage or exudates. These dressings provide protection from infection and can also hold large amount of exudates. Gauze and nonwoven dressings are used for maintaining a moist wound surface and are not suitable for wounds that have drainage or exudates. Nonadherent dressings are used for minor wounds or as a second dressing. Text Reference - p. 182

A patient is suffering from moderate to heavy drainage (exudates) from his wound. What are the types of wound dressings that the nurse should use for this patient? Select all that apply. 1 Foam dressing 2 Alginate dressing 3 Gauze and nonwoven dressings 4 Nonadherent dressing 5 Hydrocolloidal dressing

2 Custard would be the best snack because it is made from milk, egg, sugar, and vanilla. Wound healing is facilitated by protein, carbohydrates, and B vitamins. Custard also contains calcium and a small amount of vitamin A and zinc. An apple, popsicle, or potato chips do not offer this abundance of healing nutrients. Orange juice with the custard would be good to provide the vitamin C and fluid is also are needed for healing. Text Reference - p. 184

A postoperative patient now is able to eat and is requesting a snack. What snack should the nurse recommend for the patient that will facilitate wound healing? 1 Apple 2 Custard 3 Popsicle 4 Potato chips

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

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

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

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

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

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

13. The nurse is caring for a patient who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis? A) Activity intolerance B) Anxiety C) Impaired nutrition: less than body requirements D) Acute pain

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

A nurse is caring for a patient in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values? A) Sodium deficit B) Decreased prothrombin time (PT) C) Potassium deficit D) Decreased hematocrit

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

When performing a skin assessment, the nurse notes several angiomas on the chest of an older patient. Which action should the nurse take next? a. Assess the patient for evidence of liver disease. b. Discuss the adverse effects of sun exposure on the skin. c. Teach the patient about possible skin changes with aging. d. Suggest that the patient make an appointment with a dermatologist.

ANS: A Angiomas are a common occurrence as patients get older, but they may occur with systemic problems such as liver disease. The patient may want to see a dermatologist to have the angiomas removed, but this is not the initial action by the nurse. The nurse may need to teach the patient about the effects of aging on the skin and about the effects of sun exposure, but the initial action should be further assessment

The charge nurse observes the following actions being taken by a new nurse on the burn unit. Which action by the new nurse would require an intervention by the charge nurse? a. The new nurse uses clean latex gloves when applying antibacterial cream to a burn wound. b. The new nurse obtains burn cultures when the patient has a temperature of 95.2° F (35.1° C). c. The new nurse administers PRN fentanyl (Sublimaze) IV to a patient 5 minutes before a dressing change. d. The new nurse calls the health care provider for a possible insulin order when a nondiabetic patient's serum glucose is elevated.

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

A 38-year-old female patient states that she is using topical fluorouracil to treat actinic keratoses on her face. Which additional assessment information will be most important for the nurse to obtain? a. History of sun exposure by the patient b. Method of birth control used by the patient c. Length of time the patient has used fluorouracil d. Appearance of the treated areas on the patient's face

ANS: B Because fluorouracil is teratogenic, it is essential that the patient use a reliable method of birth control. The other information is also important for the nurse to obtain, but lack of reliable birth control has the most potential for serious adverse medication effects

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

ANS: B Cervical spine injuries are commonly associated with electrical burns. Therefore stabilization of the cervical spine takes precedence after airway management. The other actions are also included in the emergent care after electrical burns, but the most important action is to avoid spinal cord injury.

A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take? a. Encourage the patient to cough and auscultate the lungs again. b. Notify the health care provider and prepare for endotracheal intubation. c. Document the results and continue to monitor the patient's respiratory rate. d. Reposition the patient in high-Fowler's position and reassess breath sounds.

ANS: B The patient's history and clinical manifestations suggest airway edema and the health care provider should be notified immediately, so that intubation can be done rapidly. Placing the patient in a more upright position or having the patient cough will not address the problem of airway edema. Continuing to monitor is inappropriate because immediate action should occur

A young adult patient who is in the rehabilitation phase 6 months after a severe face and neck burn tells the nurse, "I'm sorry that I'm still alive. My life will never be normal again." Which response by the nurse is best? a. "Most people recover after a burn and feel satisfied with their lives." b. "It's true that your life may be different. What concerns you the most?" c. "It is really too early to know how much your life will be changed by the burn." d. "Why do you feel that way? You will be able to adapt as your recovery progresses."

ANS: B This response acknowledges the patient's feelings and asks for more assessment data that will help in developing an appropriate plan of care to assist the patient with the emotional response to the burn injury. The other statements are accurate, but do not acknowledge the anxiety and depression that the patient is expressing.

The nurse is reviewing laboratory results on a patient who had a large burn 48 hours ago. Which result requires priority action by the nurse? a. Hematocrit 53% b. Serum sodium 147 mEq/L c. Serum potassium 6.1 mEq/L d. Blood urea nitrogen 37 mg/dL

ANS: C Hyperkalemia can lead to fatal dysrhythmias and indicates that the patient requires cardiac monitoring and immediate treatment to lower the potassium level. The other laboratory values are also abnormal and require changes in treatment, but they are not as immediately life threatening as the elevated potassium level

When examining an older patient in the home, the home health nurse notices irregular patterns of bruising at different stages of healing on the patient's body. Which action should the nurse take first? a. Discourage the use of throw rugs throughout the house. b. Ensure the patient has a pair of shoes with non-slip soles. c. Talk with the patient alone and ask about what caused the bruising. d. Notify the health care provider so that x-rays can be ordered as soon as possible.

ANS: C The nurse should note irregular patterns of bruising, especially in the shapes of hands or fingers, in different stages of resolution. These may be indications of other health problems or abuse, and should be further investigated. It is important that the nurse interview the patient alone because, if mistreatment is occurring, the patient may not disclose it in the presence of the person who may be the abuser. Throw rugs and shoes with slippery surfaces may contribute to falls. X-rays may be needed if the patient has fallen recently and also has complaints of pain or decreased mobility. However, the nurse's first nursing action is to further assess the patient

During assessment of the patient's skin, the nurse observes a similar pattern of small, raised lesions on the left and right upper back areas. Which term should the nurse use to document these lesions? a. Confluent b. Zosteriform c. Generalized d. Symmetric

ANS: D The description of the lesions indicates that they are grouped. The other terms are inconsistent with the description of the lesions

When taking the health history of an older adult, the nurse discovers that the patient has worked in the landscaping business for 40 years. The nurse will plan to teach the patient about how to self-assess for which clinical manifestations (select all that apply)? a. Vitiligo b. Alopecia c. Intertrigo d. Erythema e. Actinic keratosis

ANS: D, E A patient who has worked as a landscaper is at risk for skin lesions caused by sun exposure such as erythema and actinic keratosis. Vitiligo, alopecia, and intertrigo are not associated with excessive sun exposure

A nurse is caring for a patient with burns who is in the later stages of the acute phase of recovery. The plan of nursing care should include which of the following nursing actions? A) Maintenance of bed rest to aid healing B) Choosing appropriate splints and functional devices C) Administration of beta adrenergic blockers D) Prevention of venous thromboembolism

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

A patient arrives in the emergency department after being burned in a house fire. The patient's burns cover the face and the left forearm. What extent of burns does the patient most likely have? A) 13% B) 25% C) 9% D) 18%

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

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

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

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

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

15. The nurse is teaching a patient with a partial-thickness wound how to wear his elastic pressure garment. How would the nurse instruct the patient to wear this garment? A) 4 to 6 hours a day for 6 months B) Daily for 2 to 3 months after the injury C) Continuously D) At night while sleeping for a year after the injury

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

29. A patient is admitted to the burn unit after being transported from a facility 1000 miles away. The patient has burns to the groin area and both legs. The burns to the lower legs are circumferential. The nurse knows to monitor closely for what as the edema in this patient increases? A) Ischemia B) Eschar C) Hyper-profusion to the burned area D) Increased fluid loss through the burned area

ISCHEMIA **As edema increases, pressure on small blood vessels and nerves in the distal extremities causes an obstruction of blood flow and consequent ischemia. This complication is similar to compartment syndrome. The physician may need to perform an escharotomy, a surgical incision into the eschar (devitalized tissue resulting from a burn), to relieve the constricting effect of the burned tissue.

8. A patient has sustained a severe burn injury and is thought to have an impaired intestinal mucosal barrier. Since this patient is considered at an increased risk for infection, what intervention will assist in avoiding increased intestinal permeability and prevent early endotoxin translocation? A) Early enteral feeding B) Administration of prophylactic antibiotics C) Bowel cleansing procedures D) Administration of stool softeners

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

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

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

An older adult patient is admitted to the hospital with dehydration resulting from prolonged vomiting. Which assessment finding by the nurse is most consistent with severe dehydration? a. The skin color over the nose and ears has a blue tint. b. The skin of the extremities is warm and dry to touch. c. Pressing the skin over the ankles causes pitting for 10 seconds. d. Pinching the skin under the clavicle causes tenting for 10 seconds.

d. Pinching the skin under the clavicle causes tenting for 10 seconds. Skin turgor is good when skin moves easily when lifted and immediately returns to its original position when released (no tenting). A loss of skin turgor occurs with dehydration and aging that will result in tenting. With hypovolemia, expected skin changes are cool without edema or central cyanosis.

An adolescent is brought to the clinic by a parent for treatment of acne. What should the nurse assess the patient for to support the existence of acne? a. Ulcers b. Wheals c. Vesicles d. Pustules

d. Pustules Pustules are elevated, superficial lesions filled with purulent fluid, such as those commonly associated with acne. Wheals, ulcers, and vesicles are not common manifestations of acne.

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

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

7. The nurse on a burn unit is caring for a patient in the acute phase of burn care. While performing an assessment during this phase of burn care, the nurse recognizes that airway obstruction related to upper airway edema may occur up to how long after the burn injury? A) 2 days B) 3 days C) 5 days D) A week

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

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 Ringer's lactate

3. Giving oral medications for pain management Large burns cause decreased peristalsis, and therefore nothing should be given by mouth. Clients with large burns may vomit, and attention is needed to prevent them from aspirating vomitus. Prophylactic intubation may be initiated if any heat or smoke has been inhaled. Fluid replacement and urine output are necessary for the treatment of the burn client.

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 The highest priority would be to maintain the airway with adequate oxygenation and ventilation. The other nursing diagnoses would not be the first priority.

A nurse is managing the fluid status of a client being treated for a burn. Which of following is an indicator of adequate fluid resuscitation? 1. Blood pressure 95/60 mmHg 2. Pulse 115 bpm 3. Patient confusion 4. Urine output 30 mL/hr

4. Urine output 30 mL/hr Fluid should be titrated to ensure a urine output of 30 to 50 mL/hr. The other assessment values are not indicators of adequate fluid hydration.

2 Characteristics of a stage II ulcer include partial-thickness loss of dermis manifesting as a shallow open ulcer with a red-pink wound bed, without slough. Stage II ulcers also may manifest an intact or open/ruptured serum-filled blister. See Table 12-13 for descriptions of Stage I, III, and IV ulcers. STUDY TIP: Rest is essential to the body and brain for good performance; think of it as recharging the battery. A run-down battery provides only substandard performance. For most students, it is better to spend seven hours sleeping and three hours studying than to cut sleep to six hours and study four hours. The improvement in the rested mind's efficiency will balance out the difference in the time spent studying. Knowing your natural body rhythms is necessary when it comes to determining the amount of sleep needed for personal learning efficiency. Text Reference - p. 185

A 90-year-old patient is being cared for at home by the family. A pressure ulcer on the right trochantor area measures 1 × 2 × 0.2 cm in depth, with a red-pink wound bed without slough. Which stage would the home health nurse document on the wound assessment form? 1 Stage I 2 Stage II 3 Stage III 4 Stage IV

1, 3, 4 Pressure ulcers develop in patients who are nonambulatory and who do not change their positions often. Patients who have quadriplegia, are disoriented, are nonambulatory, or have had a brain injury are at high risk of developing pressure ulcers. These patients cannot move by themselves and need help to change position. Therefore, they are at high risk of developing pressure ulcers. The patient who had myocardial infarction has moderate ambulation and can change positions in bed, so the risk of pressure ulcers is low. Similarly, the patient with fractures of the right humerus and rib is ambulatory and is at low risk for pressure ulcer. Text Reference - p. 184

A nurse is assessing the risks of patients for developing pressure ulcers. Which patients are at high risk for developing pressure ulcers? Select all that apply. 1 A 65-year-old female patient with quadriplegia; nonambulatory 2 A 52-year-old male patient who had suffered myocardial ischemia; moderate ambulation 3 A 49-year-old male patient with sepsis; responds in grunts; disoriented 4 A 58-year-old female patient with stroke and incontinence of urine and stool; ambulates with a wheelchair 5 A 67-year-old male patient with a history of falls and current fractures of the right humerus and one rib

1, 2, 4 Cultures can be obtained by needle aspiration, tissue culture, or swab technique. Concurrent swab specimens are obtained from wounds using wound exudates, Z-technique, and Levine's technique. A wound exudate swab is collected from the exudates before cleaning the wound. In the Z-technique, the nurse rotates a culture swab over the cleansed wound bed surface in a 10-point Z-track fashion. In Levine's technique, the nurse rotates a culture swab over a cleansed 1-cm2 area near the center of the wound using sufficient pressure to extract wound fluid from deep tissue layers. A health care provider will obtain needle and tissue punch biopsy samples. As a nurse, you can obtain cultures using the swab technique. STUDY TIP: Study goals should set out exactly what you want to accomplish. Do not simply say, "I will study for the exam." Specify how many hours, what day and time, and what material you will cover. Text Reference - p. 184

A nurse is caring for a patient suffering from a deep wound. What are the techniques by which a nurse can obtain a specimen for culture studies? Select all that apply. 1 Wound exudate swab 2 Swab using Z-technique 3 Sample by tissue punch biopsy 4 Swab using Levine's technique 5 Tissue sample using needle aspiration

1, 4, 5 Increasing the amount of protein in the diet will help to increase the synthesis of collagen, leukocytes, and fibroblasts, all of which are necessary for healing. Vitamin A helps in epithelialization, so its intake should be increased. Including a moderate amount of fats will help healing because the fats help in the synthesis of fatty acids, which are part of the cell membrane. Fluid intake should not be limited, but rather should be increased because it helps replace the fluid that is lost from perspiration and exudate formation. Vitamin C, not vitamin D, is responsible for capillary synthesis. Text Reference - p. 183

A nurse is caring for a patient who has been admitted to the trauma unit after an injury to the chest. After taking a detailed history, the nurse finds that the patient is undernourished, which might delay healing of the wound. How should the nurse plan the diet of the patient to ensure proper nutrition for adequate wound healing? Select all that apply. 1 Increase the protein intake to promote synthesis of collagen. 2 Limit fluid intake, because it may result in increased exudate. 3 Increase the intake of vitamin D to promote capillary synthesis. 4 Increase the intake of vitamin A, because it helps in epithelialization. 5 Include a moderate amount of fats to help in synthesis of fatty acids.

3 An injured extremity may become engorged with blood. Elevation of the injured extremity above the level of the heart helps to reduce pain associated with swelling by increasing the venous and lymphatic return. Compression helps to reduce vasodilation and edema. However, distal pulses should be assessed before and after a compression bandage is applied, to evaluate whether the extremity has compromised circulation. If the circulation is not compromised, a compression bandage can be used. The injured extremity should be immobilized and allowed to rest, because immobilization promotes healing by decreasing the metabolic needs of the patient. At the time of initial trauma, cold fomentation should be used to promote vasoconstriction and decrease pain, swelling, and congestion. Heat may be used 24 to 48 hours after injury to promote healing by increasing circulation at the inflamed site. Text Reference - p. 177

A nurse is designing a plan of care for a patient with a soft tissue injury and related inflammation as a result of a motor vehicle accident. Which nursing intervention should be included in the plan? 1 Avoid compression bandages, because they may compromise circulation. 2 Keep the injured extremity moving for proper blood circulation. 3 Elevate the injured extremity above the level of the heart to reduce pain. 4 Use hot fomentation to increase the circulation at the inflamed site during initial trauma care.

1, 3, 5 Signs of inflammation are pain, swelling, and redness. Pain is caused by the change in pH, nerve stimulation by chemicals, and pressure from fluid exudate. Swelling is caused by fluid shift to interstitial spaces and accumulation of fluid exudate. Redness is a result of hyperemia from vasodilation. Blackish discoloration and ulcers are not indicative of inflammation. Text Reference - p. 175

A nurse is examining an intravenous site and confirms that inflammation is present at the site. What signs of inflammation may be present in the patient? Select all that apply. 1 Pain at the site 2 Ulcers at the site 3 Swelling of the site 4 Black discoloration 5 Redness at the site

4 It is important to practice the "no touch" technique when changing the dressing to avoid wound contamination. Repositioning the patient every 20 minutes would be too frequent. However, the caregiver should reposition the patient at least every 2 hours. The skin of the patient should be inspected daily for pressure ulcers. The caregiver should be taught the proper way of disposing of contaminated dressings; they should not be disposed of with other garbage, because they can spread infection. Text Reference - p. 187

A nurse is preparing for the discharge of a patient with a pressure ulcer and includes the caregiver in the education. What should the nurse include in the home care instructions? 1 Instruct the caregiver to reposition the patient every 20 minutes. 2 Teach the caregiver to inspect the skin of the patient every 15 days. 3 Instruct the caregiver to dispose of contaminated dressings along with other garbage. 4 Teach the caregiver the "no touch" technique for changing the dressing

3, 4, 5 There are four types of debridement: surgical, mechanical, autolytic, and enzymatic. Mechanical debridement has three methods: wet-to-dry dressings, wound irrigation, and whirlpool. Whirlpool is used when minimal debris is present. Wound irrigation involves debriding the wound with high irrigation pressure. Wet-to-dry dressings involve application of open-mesh gauze moistened with normal saline. It is packed on or into a wound surface and allowed to dry. Autolytic and enzymatic are different types of debridement and are not methods of mechanical debridement. Text Reference - p. 183

A nurse is providing care to a patient who is scheduled for mechanical debridement. What are methods of mechanical debridement? Select all that apply. 1 Autolytic 2 Enzymatic 3 Whirlpool 4 Wound irrigation 5 Wet-to-dry dressings

4 Tertiary intention healing is a delayed suturing of a wound after the infection has been controlled. Because it is associated with delayed healing, the scar is larger and deeper than the scar that results from primary and secondary intention healing. The process of repair is more complex than the process of regeneration, because repair occurs by primary, secondary, and tertiary intention. Secondary intention healing is the healing of wounds whose edges cannot be approximated. Delayed closure with sutures is a form of tertiary intention healing. Primary healing takes place when wound margins are clear and concise. Text Reference - p. 177

A nursing student is learning about inflammation and wound healing. Which statement describing the process of wound healing conveys that the nursing student understands the process? 1 "Regeneration is more complex than the process of repair." 2 "Delayed closure with sutures is a secondary intention healing." 3 "Primary intention healing takes place when wound margins are irregular." 4 "Tertiary intention healing results in a larger and deeper scar."

3 With secondary healing, the wound is left open and heals from the edges inward and from the bottom up. With primary intention, the wound edges are stapled or sutured, and healing occurs until the contraction of the healing area closes the defect and brings the skin edges closer together to form a mature scar. With tertiary healing, the contaminated wound is left open and closed after the infection is controlled. Test-Taking Tip: Monitor questions that you answer with an educated guess or changed your answer from the first option you selected. This will help you to analyze your ability to think critically. Usually your first answer is correct and should not be changed without reason. Text Reference - p. 178

A patient asks the nurse what the surgeon meant by "the wound will be allowed to heal by secondary intention." How should the nurse explain this to the patient? 1 The wound will be stapled together until it heals. 2 The healing will contract the area to close the wound. 3 The wound will be left open and heal from the edges inward. 4 The wound will be sutured after the current infection is controlled.

2, 3, 5 Hyperbaric oxygen therapy involves delivering oxygen at increased atmospheric pressure. The therapy kills anaerobic bacteria in the wound, preventing further infection. It increases the killing power of WBCs and certain antibiotics. The therapy also promotes angiogenesis (growth of new blood vessels) to facilitate wound healing. Hyperbaric oxygen therapy accelerates formation of granulation tissue, which in turn accelerates the wound healing process. Text Reference - p. 182

A patient has been advised to receive hyperbaric oxygen therapy for wound healing. How does this therapy promote wound healing? Select all that apply. 1 It prevents formation of new blood vessels. 2 It kills anaerobic bacteria. 3 It increases the killing power of white blood cells (WBCs). 4 It slows down formation of granulation tissue. 5 It increases the effectiveness of certain antibiotics

3 Any compression dressing requires vigilant assessment of the circulation distal to the dressing site, because tissue and nerve damage are significant risks. Exudate and infection normally would not accompany a soft tissue injury such as a sprain. Assessment of the circulation distal to the dressing site supersedes the importance of assessing the patient's mobility. Test-Taking Tip: Read every word of each question and option before responding to the item. Glossing over the questions just to get through the examination quickly can cause you to misread or misinterpret the real intent of the question. Text Reference - p. 177

A patient has been provided with a compression dressing in an attempt to facilitate rapid healing of an ankle sprain. What is a priority nursing assessment? 1 Frequent examination of the character and quantity of exudate 2 Monitoring for signs and symptoms of local or systemic infections 3 Assessment of the patient's circulation distal to the location of the dressing 4 Assessment of the range of motion of the ankle and the patient's activity tolerance

4 Acetaminophen is an antipyretic drug that inhibits the synthesis of prostaglandins. Acetaminophen lowers body temperature by acting on the heat-regulating center in the hypothalamus. This drug should be administered around the clock to prevent acute swings in temperature. Vitamin A supplements are used to increase collagen synthesis. Corticosteroids prevent liberation of lysosomes. Hyperbaric oxygen therapy increases the power of white blood cells. Test-Taking Tip: Avoid taking a wild guess at an answer. However, should you feel insecure about a question, eliminate the alternatives that you believe are definitely incorrect, and reread the information given to make sure you understand the intent of the question. This approach increases your chances of randomly selecting the correct answer or getting a clearer understanding of what is being asked. Text Reference - p. 176

A patient has fever associated with inflammation at an injury site. The nurse administers acetaminophen to the patient around the clock. What is the rationale behind this nursing intervention? 1 To increase collagen synthesis 2 To prevent liberation of lysosomes 3 To increase power of white blood cells 4 To prevent acute swings in temperature

4 White blood cells play an important role in the body's defense and they facilitate the response to inflammation. A decreased white blood cell count causes neutropenia; a neutropenic patient is unable to mount an inflammatory response. Zinc deficiency impairs epithelialization in the wound-healing process. Protein deficiency decreases the supply of amino acids for tissue repair. Decreased red blood cell count causes anemia. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Text Reference - p. 172

A patient has sustained an injury, but has no signs or symptoms of inflammation at the site of injury. Which laboratory finding does the nurse correlate with this finding? 1 Zinc deficiency 2 Protein deficiency 3 Decreased red blood cell count 4 Decreased white blood cell count

1, 2, 5 In cases of soft tissue injuries, RICE treatment (rest, ice, compression, and elevation) is given. The affected part is immobilized and given rest. Ice or cold is applied to reduce pain and inflammation. Hot applications can be given after 24 to 48 hours. The affected part is compressed with bandages to provide support and prevent edema. The affected part should be elevated above the heart level to prevent edema and pain. Making the patient walk would increase pain and discomfort, so it is not advisable. Text Reference - p. 177

A patient is admitted to the hospital two hours following an ankle injury. A soft tissue injury is suspected. There is no external bleeding. What measures can the nurse take for this patient to help relieve the inflammation? Select all that apply. 1 Immobilize the affected part and encourage rest. 2 Provide cold application to the affected part. 3 Make the patient lie down and keep the ankle below the level of heart. 4 Make the patient walk a little distance to increase circulation in the affected area. 5 Apply a compression bandage to the ankle and check the distal pulse.

3 The local response to inflammation includes the manifestations of redness, heat, pain, swelling, and loss of function. Typical drainage from a surgical tube is serosanguionous; purulent drainage would indicate an infection. The response is normal, not a sign of infection or of impending dehiscence. The symptoms do not necessarily indicate the hernia repair was not successful. STUDY TIP: Becoming a nursing student automatically increases stress levels because of the complexity of the information to be learned and applied and because of new constraints on time. One way to decrease stress associated with school is to become very organized so that assignment deadlines or tests do not come as sudden surprises. By following a consistent plan for studying and completing assignments, you can stay on top of requirements and thereby prevent added stress. Text Reference - p. 177

A patient is one day postoperative after having a hernia repair. During the morning assessment, the nurse notes that the patient has incisional pain, a 99.2° F temperature, slight redness at the incision margins, and 20 mL of serosanguineous drainage in the Jackson-Pratt drain. Based on these assessment data, what conclusion would the nurse make? 1 The abdominal incision is showing signs of an infection. 2 The patient's abdominal hernia repair was not successful. 3 The patient is experiencing a normal inflammatory response. 4 The abdominal incision is showing signs of impending dehiscence.

1, 4, 5 Vitamin C is a very important nutrient that helps in wound healing. Deficiency of vitamin C delays formation of collagen fibers and capillary development. The nurse should encourage the patient to eat guava, strawberries, and kiwi, because these fruits are rich in vitamin C. Apples and bananas are not rich sources of vitamin C. Text Reference - p. 181

A patient is suffering from multiple lacerations and wounds. Which food items should be encouraged to promote healing in the patient? Select all that apply. 1 Guava 2 Apple 3 Banana 4 Strawberry 5 Kiwi fruits

1, 2, 5 Persistent hyperglycemia (steroid diabetes) can occur because of altered glucose metabolism. Because the antiinflammatory response is depressed as a result of increased cortisol levels, the wounds of patients receiving long-term corticosteroid therapy tend to heal slowly. Because of the depressed immune system, fever may be blunted in this patient. Corticosteroid therapy does not affect the risk of bleeding from the wound or the risk of bone infection. Text Reference - p. 181

A patient receiving long-term corticosteroid therapy for rheumatoid arthritis is admitted to the hospital with a wound of the left upper extremity. What should the nurse expect while assessing this patient? Select all that apply. 1 The patient is at risk of hyperglycemia. 2 The wound of this patient will heal slowly. 3 There will be reduced bleeding from the wound. 4 The patient is at a risk of developing bone infection. 5 The symptom of fever may be blunted in this patient.

Which integumentary assessment data from an older patient admitted with bacterial pneumonia is of most concern for the nurse? a. Reports a history of allergic rashes b. Scattered macular brown areas on extremities c. Skin brown and wrinkled, skin tenting on forearm d. Longitudinal nail bed ridges noted; sparse scalp hair

ANS: A Because the patient will be receiving antibiotics to treat the pneumonia, the nurse should be most concerned about her history of allergic rashes. The nurse needs to do further assessment of possible causes of the allergic rashes and whether she has ever had allergic reactions to any drugs, especially antibiotics. The assessment data in the other response would be normal for an older patient

Which activities can the nurse working in the outpatient clinic delegate to a licensed practical/vocational nurse (LPN/LVN) (select all that apply)? a. Administer patch testing to a patient with allergic dermatitis. b. Interview a new patient about chronic health problems and allergies. c. Apply a sterile dressing after the health care provider excises a mole. d. Teach a patient about site care after a punch biopsy of an upper arm lesion. e. Explain potassium hydroxide testing to a patient with a superficial skin infection.

ANS: A, C Skills such as administration of patch testing and sterile dressing technique are included in LPN/LVN education and scope of practice. Obtaining a health history and patient education require more critical thinking and registered nurse (RN) level education and scope of practice

The nurse assesses a circular, flat, reddened lesion about 5 cm in diameter on a middle-aged patient's ankle. How should the nurse determine if the lesion is related to intradermal bleeding? a. Elevate the patient's leg. b. Press firmly on the lesion. c. Check the temperature of the skin around the lesion. d. Palpate the dorsalis pedis and posterior tibial pulses.

ANS: B If the lesion is caused by intradermal or subcutaneous bleeding or a nonvascular cause, the discoloration will remain when direct pressure is applied to the lesion. If the lesion is caused by blood vessel dilation, blanching will occur with direct pressure. The other assessments will assess circulation to the leg, but will not be helpful in determining the etiology of the lesion

A patient reports chronic itching of the ankles and continuously scratches the area. Which assessment finding will the nurse expect? a. Hypertrophied scars on both ankles b. Thickening of the skin around the ankles c. Yellowish-brown skin around both ankles d. Complete absence of melanin in both ankles

ANS: B Lichenification is likely to occur in areas where the patient scratches the skin frequently. Lichenification results in thickening of the skin with accentuated normal skin markings. Vitiligo is the complete absence of melanin in the skin. Keloids are hypertrophied scars. Yellowish-brown skin indicates jaundice. Vitiligo, keloids, and jaundice do not usually occur as a result of scratching the skin

Which action will the nurse include in the plan of care for a patient in the rehabilitation phase after a burn injury to the right arm and chest? a. Keep the right arm in a position of comfort. b. Avoid the use of sustained-release narcotics. c. Teach about the purpose of tetanus immunization. d. Apply water-based cream to burned areas frequently.

ANS: D Application of water-based emollients will moisturize new skin and decrease flakiness and itching. To avoid contractures, the joints of the right arm should be positioned in an extended position, which is not the position of comfort. Patients may need to continue the use of opioids during rehabilitation. Tetanus immunization would have been given during the emergent phase of the burn injury

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

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

4 A patient with a total Braden score of 16 or less is considered to be at risk for pressure ulcers. Pressure ulcers can be prevented by using an established risk assessment tool; repositioning frequently (every one to two hours); using devices to reduce pressure and shearing force (e.g., alternating pressure mattresses, foam mattresses, wheelchair cushions, padded commode seats, boots [foam, air], lift sheets); removing excessive moisture on the skin; avoiding massage over bony prominences; positioning with pillows; and assisting the patient in maintaining a healthy weight. Moist gauze dressings are appropriate for yellow pressure ulcers, not for patients who are assessed at risk for pressure ulcers. Text Reference - p. 186

An 85-year-old patient is assessed to have a score of 16 on the Braden Scale. Based on this information, the nurse will plan which intervention for this patient? 1 Massage the pressure points every shift. 2 Apply moist gauze dressings over the bony prominences. 3 Elevate the head of bed to 90 degrees when the patient is supine. 4 Implement an every two hours turning schedule with skin assessment.

A public health nurse has reviewed local data about the incidence and prevalence of burn injuries in the community. These data are likely to support what health promotion effort? A) Education about home safety B) Education about safe storage of chemicals C) Education about workplace health threats D) Education about safe driving

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

A nurse on a burn unit is caring for a patient in the acute phase of burn care. While performing an assessment during this phase of burn care, the nurse recognizes that airway obstruction related to upper airway edema may occur up to how long after the burn injury? A) 2 days B) 3 days C) 5 days D) 1 week

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

A patient is admitted to the burn unit after being transported from a facility 1000 miles away. The patient has burns to the groin area and circumferential burns to both upper thighs. When assessing the patient's legs distal to the wound site, the nurse should be cognizant of the risk of what complication? A) Ischemia B) Referred pain C) Cellulitis D) Venous thromboembolism (VTE)

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

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

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

A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurse's immediate, priority concern when planning this patient's care? A) Fluid status B) Risk of infection C) Nutritional status D) Psychosocial coping

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

A patient in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what? A) Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis B) Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis C) Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis D) Hypokalemia, hyponatremia, elevated hematocrit, and metabolic alkalosis

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

A patient has sustained a severe burn injury and is thought to have an impaired intestinal mucosal barrier. Since this patient is considered at an increased risk for infection, what intervention will best assist in avoiding increased intestinal permeability and prevent early endotoxin translocation? A) Early enteral feeding B) Administration of prophylactic antibiotics C) Bowel cleansing procedures D) Administration of stool softeners

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

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

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

A patient who is in the acute phase of recovery from a burn injury has yet to experience adequate pain control. What pain management strategy is most likely to meet this patient's needs? A) A patient-controlled analgesia (PCA) system B) Oral opioids supplemented by NSAIDs C) Distraction and relaxation techniques supplemented by NSAIDs D) A combination of benzodiazepines and topical anesthetics

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

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

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

A nurse has reported for a shift at a busy burns and plastics unit in a large university hospital. Which patient is most likely to have life-threatening complications? A) A 4-year-old scald victim burned over 24% of the body B) A 27-year-old male burned over 36% of his body in a car accident C) A 39-year-old female patient burned over 18% of her body D) A 60-year-old male burned over 16% of his body in a brush fire

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

A patient is in the acute phase of a burn injury. One of the nursing diagnoses in the plan of care is Ineffective Coping Related to Trauma of Burn Injury. What interventions appropriately address this diagnosis? Select all that apply. A) Promote truthful communication. B) Avoid asking the patient to make decisions. C) Teach the patient coping strategies. D) Administer benzodiazepines as ordered. E) Provide positive reinforcement.

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

A patient's burns have required a homograft. During the nurse's most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurse's most appropriate response? A) Perform mechanical dÈbridement to remove the exudate and prevent further infection. B) Inform the primary care provider promptly because the graft may need to be removed. C) Perform range of motion exercises to increase perfusion to the graft site and facilitate healing. D) Document this finding as an expected phase of graft healing.

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

A patient has experienced an electrical burn and has developed thick eschar over the burn site. Which of the following topical antibacterial agents will the nurse expect the physician to order for the wound? A) Silver sulfadiazine 1% (Silvadene) water-soluble cream B) Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream C) Silver nitrate 0.5% aqueous solution D) Acticoat

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

The nurse is preparing the patient for mechanical dÈbridement and informs the patient that this will involve which of the following procedures? A) A spontaneous separation of dead tissue from the viable tissue B) Removal of eschar until the point of pain and bleeding occurs C) Shaving of burned skin layers until bleeding, viable tissue is revealed D) Early closure of the wound

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

A patient who was burned in a workplace accident has completed the acute phase of treatment and the plan of care has been altered to prioritize rehabilitation. What nursing action should be prioritized during this phase of treatment? A) Monitoring fluid and electrolyte imbalances B) Providing education to the patient and family C) Treating infection D) Promoting thermoregulation

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

A nurse who is taking care of a patient with burns is asked by a family member why the patient is losing so much weight. The patient is currently in the intermediate phase of recovery. What would be the nurse's most appropriate response to the family member? A) ìHe's on a calorie-restricted diet in order to divert energy to wound healing.î B) ìHis body has consumed his fat deposits for fuel because his calorie intake is lower than normal.î C) ìHe actually hasn't lost weight. Instead, there's been a change in the distribution of his body fat.î D) ìHe lost many fluids while he was being treated in the emergency phase of burn care.î

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

A home care nurse is performing a visit to a patient's home to perform wound care following the patient's hospital treatment for severe burns. While interacting with the patient, the nurse should assess for evidence of what complication? A) Psychosis B) Post-traumatic stress disorder C) Delirium D) Vascular dementia

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

A triage nurse in the emergency department (ED) receives a phone call from a frantic father who saw his 4-year-old child tip a pot of boiling water onto her chest. The father has called an ambulance. What would the nurse in the ED receiving the call instruct the father to do? A) Cover the burn with ice and secure with a towel. B) Apply butter to the area that is burned. C) Immerse the child in a cool bath. D) Avoid touching the burned area under any circumstances.

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

A patient has experienced burns to his upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action? A) Instruct the patient to keep the wound site in a dependent position. B) Administer PRN analgesia as ordered. C) Assess the patient's peripheral pulses distal to the dressing. D) Assist with passive range of motion exercises to ìsetî the new dressing.

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

A nurse is teaching a patient with a partial-thickness wound how to wear his elastic pressure garment. How would the nurse instruct the patient to wear this garment? A) 4 to 6 hours a day for 6 months B) During waking hours for 2 to 3 months after the injury C) Continuously D) At night while sleeping for a year after the injury

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

The current phase of a patient's treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the patient is in what phase of burn care? A) Emergent B) Immediate resuscitative C) Acute D) Rehabilitation

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

A nurse is developing a care plan for a patient with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. What is the best rationale for this intervention? A) To prevent neuropathies B) To prevent wound breakdown C) To prevent contractures D) To prevent heterotopic ossification

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

A patient is brought to the emergency department from the site of a chemical fire, where he suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the patient's arm? A) Superficial partial-thickness B) Deep partial-thickness C) Full partial-thickness D) Full-thickness

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

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

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

An occupational health nurse is called to the floor of a factory where a worker has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to ìcool the burn.î How should the nurse cool the burn? A) Apply ice to the site of the burn for 5 to 10 minutes. B) Wrap the patient's affected extremity in ice until help arrives. C) Apply an oil-based substance or butter to the burned area until help arrives. D) Wrap cool towels around the affected extremity intermittently.

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

A nurse is caring for a patient who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis? A) Activity Intolerance B) Anxiety C) Ineffective Coping D) Acute Pain

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

A nurse is performing a home visit to a patient who is recovering following a long course of inpatient treatment for burn injuries. When performing this home visit, the nurse should do which of the following? A) Assess the patient for signs of electrolyte imbalances. B) Administer fluids as ordered. C) Assess the risk for injury recurrence. D) Assess the patient's psychosocial state.

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

An emergency department nurse has just admitted a patient with a burn. What characteristic of the burn will primarily determine whether the patient experiences a systemic response to this injury? A) The length of time since the burn B) The location of burned skin surfaces C) The source of the burn D) The total body surface area (TBSA) affected by the burn

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

While performing a patient's ordered wound care for the treatment of a burn, the patient has made a series of sarcastic remarks to the nurse and criticized her technique. How should the nurse best interpret this patient's behavior? A) The patient may be experiencing an adverse drug reaction that is affecting his cognition and behavior. B) The patient may be experiencing neurologic or psychiatric complications of his injuries. C) The patient may be experiencing inconsistencies in the care that he is being provided. D) The patient may be experiencing anger about his circumstances that he is deflecting toward the nurse.

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

12. An emergency department nurse learns from the paramedics that they are transporting a patient who has suffered injury from a scald from a hot kettle. What factors does the nurse know are considered when determining the depth of burn? A) Causative agent B) Visual observation of burned area C) Area of body burned D) Circumstances of the accident

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

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

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

1. A patient is brought to the Emergency Department from the site of a chemical fire. The paramedics report that the patient has a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. When you assess the patient he verbalizes no pain in the right arm and the skin appears charred. Based upon these assessment findings, what is the depth of the burn on the patient's right arm? A) Superficial partial-thickness B) Deep partial-thickness C) Full partial-thickness D) Full-thickness

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

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

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

3. A patient in the emergent/resuscitative phase of a burn injury has had her lab work drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what? A) Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis B) Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis C) Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis D) Hypokalemia, hyponatremia, elevated hematrocrit, and metabolic alkalosis

HYPERKALEMIA, HYPONATREMIA, ELEVATED HEMATOCRIT AND METABOLIC ACIDOSIS **Fluid and electrolyte changes in the emergent/resuscitative phase of a burn injury include hyperkalemia related to the release of potassium into the extracellular fluid, hyponatremia from large amount of sodium lost in trapped edema fluid, hemoconcentration that leads to an increased hematocrit, and loss of bicarbonate ions that results in metabolic acidosis.

14. The triage nurse in the emergency department (ED) receives a phone call from a frantic father who saw his 4-year-old child tip a pot of boiling water onto her chest. The father has called an ambulance. What would the nurse in the ED receiving the call instruct the father to do? A) Cover the burn with ice and secure with a towel. B) Apply butter to the area that is burned. C) Immerse the child in a cool bath. D) Avoid touching the burned area and seek medical attention.

IMMERSE THE CHILD IN A COOL BATH **After the flames or heat source have been removed or extinguished, the burned area and adherent clothing are soaked with cool water briefly to cool the wound and halt the burning process. Cool water is the best first-aid measure. You do not put ice on the burn, nor do you put butter on the burn. You do not need to avoid touching the burn.

19. The nursing students are doing clinical hours on the burn unit. A nurse is developing a care plan for a patient with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. A nursing student asks why this goal is important when the patient is fighting for his life. What should the burn nurse respond? A) To prevent neuropathies B) To prevent wound breakdown C) To prevent contractures D) To prevent heterotopic ossification

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

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

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

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

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

11. A patient with a partial-thickness burn injury had Biobrane applied 2 weeks ago. The nurse notices that the Biobrane is separating from the burn wound. What is the appropriate nursing intervention when this separation occurs? A) Reinforce the Biobrane dressing with another piece of Biobrane. B) Remove the Biobrane dressing and apply a new dressing. C) Trim away the separated Biobrane. D) Notify the physician for further emergency related orders.

TRIM AWAY THE SEPARATED BIOBRANE **As the Biobrane gradually separates, it is trimmed, leaving a healed wound. When the Biobrane dressing adheres to the wound, the wound remains stable and the Biobrane can remain in place for 3 to 4 weeks. You would not reinforce the Biobrane, or remove it and apply a new dressing. Nor would you notify the physician for further orders.

2 Cigarettes contain nicotine, which is a potent vasoconstrictor, and thus impedes blood flow to healing areas and delays wound healing. A decreased blood supply in fatty tissue is a consequence of obesity. Advanced age may result in slow collagen synthesis by fibroblasts. A decreased supply of nutrients to the injured area occurs due to inadequate blood supply. Text Reference - p. 181

The nurse is caring for a patient who has a pressure ulcer. The patient has a 20-year history of smoking. What effect does smoking have on wound healing? 1 It decreases the blood supply in fatty tissue. 2 It impedes blood flow to healing areas. 3 It slows collagen synthesis by fibroblasts. 4 It decreases the supply of nutrients to the injured area.

2, 4, 5 The diet should be high in proteins to promote wound healing. High carbohydrate intake should be encouraged to help meet the high metabolic rate associated with burns. Fluid intake should be increased to compensate for the fluid loss. Sodium and potassium are restricted during the acute phase of a burn injury, not two weeks after the injury. Text Reference - p. 183

The nurse is caring for a patient who sustained full-thickness burns two weeks ago. The nurse weighs the patient and documents the weight. The nurse finds that the patient is losing weight. What adjustments should be made in the diet to ensure the metabolic requirements of the patient are being met? Select all that apply. 1 Low-sodium diet 2 High-protein intake 3 Low-potassium diet 4 High-carbohydrate intake 5 Adequate intake of water

1, 5, 6 The nurse should assess this patient's vital signs; increase in temperature, pulse, and respiratory rates indicate the presence of infection. It is important for the nurse to note vital signs when an inflammation is present. Older adults have a blunted febrile response to infection, and body temperature may not rise as expected. Loss of function occurs due to pain and edema. Edema, erythema, and pain are local manifestations of inflammation. Text Reference - p. 176

The nurse is caring for an older adult who has a compound fracture of the radius. The nurse observes manifestations of inflammation. Which symptoms should the nurse note as signs of infection in this older patient? Select all that apply. 1 Fever 2 Pain 3 Presence of edema 4 Presence of erythema 5 Increased pulse 6 Increased respiratory rate

1 A patient with rheumatoid arthritis who is being treated with a nonsteroidal antiinflammatory drug (such as piroxicam) may show a blunted febrile response to infection. Prednisone is a corticosteroid and is used to treat inflammation associated with asthma; a decreased synthesis of lymphocytes is a side effect of the drug. Chlorhexidine is an antiseptic used to clean the wound; this drug may not result in blunted febrile response. Becaplermin is not a nonsteroidal antiinflammatory drug and does not blunt febrile response to infection. Test-Taking Tip: Chart/exhibit items present a situation and ask a question. A variety of objective and subjective information is presented about the patient in formats such as the medical record (e.g., laboratory test results, results of diagnostic procedures, progress notes, health care provider orders, medication administration record, health history), physical assessment data, and assistant/patient interactions. After analyzing the information presented, the test taker answers the question. These questions usually reflect the analyzing level of cognitive thinking. In a clinical exam, you may be expected to select instruments, arrange instruments, and/or perform some other task. Acquaint yourself with the physical facility. If the required procedures are not clear to you, ask for clarification. Text Reference - p. 176

The nurse is reviewing the medical reports of four patients. Which patient may show a blunted febrile response to infection? 1 Patient A 2 Patient B 3 Patient C 4 Patient D

2 The migration of fibroblasts occurs in the granulation phase which lasts from five days to four weeks. In this phase collagen is secreted and there is an abundance of capillary buds in the wound making it fragile. The initial phase lasts from three to five days. In this phase, the migration of epithelial cells takes place. The clot serves as a meshwork for starting capillary growth. The maturation phase lasts from seven days to several months. In this phase, remodeling of collagen and strengthening of the scar occurs. Regeneration is not the phase of primary intention healing. Text Reference - p. 178

The nurse recalls that primary intention healing takes place in various phases. Which phase best describes the migration of fibroblasts? 1 Initial phase 2 Granulation phase 3 Maturation phase 4 Regeneration phase

4 Excess granulation tissue, the excess soft pink tissue on the wound, is what this complication of wound healing is called. Adhesions are bands of scar tissue that form between or around organs. Wound contraction, which is a normal part of healing, is a complication when it results in deformity by shortening the tissue and impairing function. Keloid formation is a great protrusion of scar tissue that extends beyond the wound edges and may be uncomfortable. Text Reference - p. 180

The patient previously had a breast reduction. She has come to the surgeon's office complaining about excess soft pink tissue where a scar should be forming. What complication of wound healing does the nurse recognize this to be? 1 Adhesion 2 Contractions 3 Keloid formation 4 Excess granulation tissue

3 Elevation of an extremity above the level of the heart increases venous and lymphatic return. To reduce the risk of compromised perfusion, the nurse should check the patient's reports for reduced arterial circulation before elevating the injured extremity. Diabetes does not cause complications due to elevation of an injured extremity. The nurse should check the patient's history for cancer and other wounds before administering becaplermin. Taking a nonsteroidal antiinflammatory drug may blunt the febrile response, but it does not cause complications while elevating an injured extremity. Test-Taking Tip: Monitor questions that you answer with an educated guess or changed your answer from the first option you selected. This will help you to analyze your ability to think critically. Usually your first answer is correct and should not be changed without reason. Text Reference - p. 177

The primary health care provider instructs the nurse to elevate a patient's injured extremity. What should the nurse check for in the patient's reports before elevating the patient's extremity? 1 Diabetes 2 Cancer and other wounds 3 Reduced arterial circulation 4 Nonsteroidal antiinflammatory drug treatment

3 With Crohn's disease, a fistula may have formed between the bowel and the vagina. The nurse first should assess the patient and the drainage from the vagina. Then the nurse should notify the health care provider, document the occurrence and care prescribed, provide care prescribed, and document the care and patient response. Test-Taking Tip: The following are crucial requisites for doing well on the NCLEX exam: (1) A sound understanding of the subject; (2) The ability to follow explicitly the directions given at the beginning of the test; (3) The ability to comprehend what is read; (4) The patience to read each question and set of options carefully before deciding how to answer the question; (5) The ability to use the computer correctly to record answers; (6) The determination to do well; (7) A degree of confidence. Text Reference - p. 179

The unlicensed assistive personnel (UAP) is assisting the patient with Crohn's disease with perineal care. The UAP tells the nurse that the patient had feces coming from the vagina. What should the nurse do about this situation? 1 Notify the health care provider 2 Document the fistula formation 3 Assess the patient and vaginal drainage 4 Have the UAP apply a dressing to the vagina

10. The nurse is preparing the patient for mechanical debridement and informs the patient that this will involve: A) A spontaneous separation of dead tissue from the viable tissue B) Use of surgical scissors, scalpels or forceps to remove the eschar until the point of pain and bleeding occurs C) Shaving of burned skin layers until bleeding, viable tissue is revealed D) Early closure of the wound

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

4 Prednisone is a corticosteroid drug that interferes with the synthesis of lymphocytes, resulting in a decreased white blood cell count. Prednisone does not interfere with prothrombin time. Prednisone does not increase red blood cell count because it does not stimulate erythropoiesis. Serum protein levels are not affected by prednisone. Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect. Text Reference - p. 176

What does the nurse expect to find in the laboratory report of a patient taking prednisone for rheumatoid arthritis? 1 Increased prothrombin time 2 Increased red blood cell count 3 Decreased serum protein levels 4 Decreased white blood cell count

1 Surgical removal is the best treatment for inflammation of the appendix to prevent further complications. Antipyretics are used to reduce fever that may be associated with appendicitis, but will not promote healing. Antimicrobials are used to kill bacteria that may be involved but in a life-threatening situation, surgery is required. Corticosteroids reduce inflammation but cause immunosuppression, reducing the body's ability to fight infection. Text Reference - p. 179

What is the best choice of treatment for a patient who has acute, life-threatening inflammation of the appendix? 1 Surgery 2 Antipyretics 3 Antimicrobials 4 Corticosteroids

4 Heat application is used to localize the inflammatory agents and promote healing by increasing the circulation to the inflamed site and subsequent removal of debris. Cold application decreases congestion and promotes vasoconstriction at the site of inflammation. Immobilizing the inflamed area with a cast prevents further tissue injury. Text Reference - p. 177

What is the purpose of applying heat at the site of inflammation? 1 To decrease congestion 2 To promote vasoconstriction 3 To prevent further tissue injury 4 To localize the inflammatory agents

3 Macrophages act like a clean-up crew. They phagocytize the leftover debris, bacteria, and dead cells at the injury site essentially clean the area before healing. Prostaglandins cause vasodilation. Complement components stimulate histamine release. Serotonin stimulates smooth muscle contraction. Text Reference - p. 173

What is the role of macrophages in the body? 1 To cause vasodilation 2 To stimulate histamine release 3 To clean the area before healing 4 To stimulate smooth muscle contraction

1 The vitamin B complex acts as coenzymes. Vitamin A accelerates epithelialization. Vitamin D facilitates calcium absorption. Vitamin C assists in the synthesis of collagen. Text Reference - p. 176

What is the role of the vitamin B complex? 1 Acts as coenzymes 2 Accelerates epithelialization 3 Facilitates calcium absorption 4 Assists in synthesis of collagen

3 A WBC count of 8500/μL and a temperature of 98.4° F are within the normal range. A normal WBC is 4000 to 11,000/μL. An elevated WBC count and elevated temperature are indicators of infection. Test-Taking Tip: After you have eliminated one or more choices, you may discover that two of the options are very similar. This can be very helpful, because it may mean that one of these look-alike answers is the best choice and the other is a very good distractor. Test both of these options against the stem. Ask yourself which one completes the incomplete statement grammatically and which one answers the question more fully and completely. The option that best completes or answers the stem is the one you should choose. Here, too, pause for a few seconds, give your brain time to reflect, and recall may occur. Text Reference - p. 174

When assessing a patient who is receiving cefazolin for the treatment of a bacterial infection, which data suggest that treatment has been effective? 1 White blood cell (WBC) count 8000/μL, temperature 101° F 2 WBC count 4000/μL, temperature 101° F 3 WBC count 8500/μL, temperature 98.4° F 4 WBC count 16,500/μL, temperature 98.8° F

1, 2 Applying a compression bandage may compromise the patient's blood circulation. Therefore, the nurse should assess the distal pulses to evaluate blood circulation before and after applying a compression bandage. The nurse should check capillary refill before and after applying a compression bandage to ensure adequate blood circulation. Serum protein levels should be monitored after performing negative-pressure wound therapy. Partial thromboplastin time should be checked after performing negative-pressure wound therapy. The patient's fluid and electrolyte balance should be checked after applying negative-pressure wound therapy because fluid and electrolyte loss may occur. Text Reference - p. 177

Which factors should the nurse check in a patient before applying a compression bandage? Select all that apply. 1 Distal pulses 2 Capillary refill 3 Serum protein levels 4 Partial thromboplastin time 5 Fluid and electrolyte balance

4 Prostaglandins are a group of lipids produced at sites of tissue damage or infection and are involved in injury response. Prostaglandins are derived from arachidonic acid by sequential oxidation. Kinins are peptides that are produced and act at the site of tissue injury or inflammation. Kinins are produced from precursor factor kininogen as a result of activation of Hageman factor. Histamine is an organic nitrogenous compound involved in local immune responses. It is stored in granules of basophils, mast cells, and platelets. Serotonin is stored in platelets, mast cells, and enterochromaffin cells of the gastrointestinal (GI) tract. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Text Reference - p. 174

Which inflammatory mediator is produced from arachidonic acid? 1 Kinin 2 Histamine 3 Serotonin 4 Prostaglandin

1 Histamine is released by the cells in response to inflammation; this chemical causes vasodilation and increases capillary permeability at the injury site. Leukotrienes stimulate chemotaxis and cause smooth muscle constriction along with capillary permeability. Complement components such as C4a and C3a stimulate histamine release and chemotaxis. Text Reference - p. 174

Which mediator of inflammation causes vasodilation and increases capillary permeability at the injury site? 1 Histamine 2 Leukotrienes 3 Complement component C4a 4 Complement component C3a

1 Kinins are produced by the activation of the Hageman factor. They cause contraction of smooth muscle and vasodilation. Enterochromaffin cells of the gastrointestinal tract store serotonin. Arachidonic acid produces leukotrienes. Anaphylatoxic agents generated from complement pathway activation produce complement component C5a. Text Reference - p. 174

Which mediator of inflammation is produced by activation of the Hageman factor? 1 Kinins 2 Serotonin 3 Leukotrienes 4 Complement component C5a

1 Serotonin is stored in the enterochromaffin cells of the gastrointestinal tract. Histamine is stored in the granules of basophils, mast cells, and platelets. Bradykinin is produced after activation of the Hageman factor of the clotting system. Prostaglandin is produced from arachidonic acid. Text Reference - p. 174

Which mediator of inflammation is stored in the enterochromaffin cells of the gastrointestinal tract? 1 Serotonin 2 Histamine 3 Bradykinin 4 Prostaglandin

1 Aspirin is an antiinflammatory drug that reduces capillary permeability in the body. Ibuprofen is a nonsteroidal antiinflammatory drug that inhibits prostaglandin synthesis. Piroxicam is a nonsteroidal antiinflammatory drug that inhibits the synthesis of prostaglandin. Acetaminophen helps maintain thermoregulation by acting on the heat-regulating center in the hypothalamus. Text Reference - p. 176

Which medication may reduce capillary permeability? 1 Aspirin 2 Piroxicam 3 Ibuprofen 4 Acetaminophen

3 Fever is mediated by a host macrophage product called endogenous pyrogen (EP) that stimulates the proliferation of T cells. Fever increases the action of neutrophils and promotes phagocytosis. Vasodilators increase blood flow rate. Fever increases destruction of microorganisms by enhancing the activity of interferon. Test-Taking Tip: You have at least a 25 percent chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses. Text Reference - p. 175

Which physiologic change is associated with fever during inflammatory conditions? 1 Increased blood flow rate 2 Decreased neutrophil action 3 Increased proliferation of T cells 4 Suppressed activity of interferon

2 In tuberculosis, the Mycobacterium bacillus is walled off, and the macrophages accumulate and fuse to form a multinucleated giant cell that engulfs the bacterial particle. This giant cell is encapsulated by collagen and forms granuloma. Tuberculosis causes chronic inflammation. Ivory to yellow-green exudate indicates infection, but is not seen in tuberculosis. Tissue damage by complement activation can occur in rheumatoid arthritis. Text Reference - p. 174

While reviewing a patient's laboratory reports, the nurse finds Mycobacterium strains in the patient's sputum. Which physiologic change does the nurse expect in this patient? 1 Acute inflammation 2 Granuloma formation 3 Ivory to yellow-green exudate 4 Tissue damage by complement activation

39. A burn patient is transitioning from the acute phase of the injury to the rehabilitation phase. The patient tells the nurse "I can't wait to have surgery to reconstruct my face so I look normal again." What would be the nurse's best response? A) "You know, nothing can be done until your scars mature. It is something the doctor will talk to you about in the first few years after discharge." B) "That is something for you to talk to your doctor about." C) "I know this is really important to you, but you have to realize that no one can make you look like you used to." D) "You will have most of these scars for the rest of your life."

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

21. A nurse taking care of a burn patient is asked why the patient is losing so much weight. What would be the nurse's most appropriate answer? A) "Your body has built up extra fat deposits even though you haven't been eating very much." B) "Your body has used your fat deposits for fuel because you haven't been eating very much." C) Your reserve fat deposits have been catabolized because you have been eating so much." D) You have lost fluids and you haven't eaten very much."

YOUR BODY HAS USED YOUR FAT DEPOSITS FOR FUEL BECAUSE YOU HAVEN'T BEEN EATING VERY MUCH **Patients lose a great deal of weight during recovery from severe burns. Reserve fat deposits are catabolized, fluids are lost, and caloric intake may be limited.

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

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

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

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

The nurse is preparing to perform an assessment for a newly admitted patient with a potential hematologic disorder and petechiae. What does the nurse anticipate finding when assessing this patient? a. Tiny purple spots on the skin b. Large ecchymotic areas on the skin c. Hyperkeratotic papules and plaques d. Small, raised red areas on the soles of the feet

a. Tiny purple spots on the skin Petechiae present as tiny purple spots on the skin. Large ecchymotic areas are purpura. Hyperkeratotic papules and plaques characterize actinic keratosis. Small, raised red areas on the soles of the feet signify Osler's nodes.

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

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

The nurse is assessing a white patient's skin color for cyanosis. The best place for the nurse to assess this is the a. lips. b. legs. c. wrists. d. sclera.

a. lips. On light-skinned individuals, cyanosis or a grayish blue tone initially appears on the lips, nail beds, earlobes, mucous membranes, palms of the hands, and soles of the feet.

A patient with thrombocytopenia secondary to sepsis has small, pinpoint deposits of blood visible through the skin on the anterior and posterior chest. The nurse will document this skin abnormality as a. petechiae. b. erythema. c. ecchymosis. d. telangiectasia.

a. petechiae. Petechiae are pinpoint, discrete deposits of blood less than 1 to 2 mm in the extravascular tissues and visible through the skin or mucous membranes. Erythema is redness occurring in patches of variable size and shape. Telangiectasia is visibly dilated, superficial, cutaneous small blood vessels. Ecchymosis is a large, bruise-like lesion caused by a collection of extravascular blood in the dermis and subcutaneous tissue.

A patient is ordered to receive acetaminophen 650 mg per rectum every 6 hours as needed for fever greater than 102° F. Which parameter would the nurse monitor, other than temperature, if the patient requires this medication? a) Pain level b) Intake and output c) Oxygen saturation d) Level of consciousness

b) Intake and output Because fever can lead to excessive perspiration and evaporation of body fluid via the skin, the nurse should monitor the patient's overall intake and output to be sure that the patient remains in proper fluid balance. Pain, oxygen saturation, and level of consciousness will also be monitored as with all patients, but intake and output are the priority for this patient.

A 65-year-old stroke patient with limited mobility has a purple area of suspected deep tissue jury on the left greater trochanter. Which nursing diagnoses is/are most appropriate (select all that apply)? a. Acute pain related to tissue damage and inflammation b. Impaired skin integrity related to immobility and decreased sensation c. Impaired tissue integrity related to inadequate circulation secondary to pressure d. Risk for infection related to loss of tissue integrity and undernutrition secondary to stroke

b & c

A postoperative patient is now able to eat and is requesting a snack. What snack should the nurse recommend for the patient that will facilitate wound healing? a) Apple b) Custard c) Popsicle d) Potato chips

b) Custard Custard would be the best snack because it is made from milk, egg, sugar, and vanilla. Wound healing is facilitated by protein, carbohydrates, and B vitamins. Custard also contains calcium and a small amount of vitamin A and zinc. The other snacks do not offer this abundance of healing nutrients. Orange juice with the custard would be good to provide the vitamin C and fluid that are also needed for healing.

A patient with pneumonia has a fever of over 103o F. What should the nurse do to manage the patient's fever? a) Administer aspirin on a scheduled basis around the clock. b) Provide acetaminophen every 4 hours to maintain consistent blood levels. c) Administer acetaminophen when the patient's oral temperature exceeds 103.5° F. d) Provide drug interventions if complementary and alternative therapies have failed.

b) Provide acetaminophen every 4 hours to maintain consistent blood levels. Antipyretics should be given around the clock to prevent acute swings in temperature. ASA would not be the drug of choice because of its antiplatelet action and accompanying risk of bleeding. When treating fever, drug interventions are not normally withheld in lieu of complementary therapies.

A patient had abdominal surgery last week. The patient calls the office and says the wound is now draining thick white material and it smells funny. How should the nurse document this drainage? a) Serous b) Purulent c) Fibrinous d) Catarrhal

b) Purulent Purulent drainage consists of WBCs, microorganisms, and other debris that signal an infection. Serous drainage is a thin, watery, clear or yellowish drainage frequently seen with broken blisters. Fibrinous drainage occurs with fibrinogen leakage and is thick and sticky. Catarrhal drainage occurs when there are cells that produce mucus associated with the inflammatory response.

The patient has inflammation and is complaining of malaise, nausea, and anorexia. The nurse explains to the patient that these manifestations are related to inflammation in what way? a) Local response b) Systemic response c) Infectious response d) Acute inflammatory response

b) Systemic response The systemic response to inflammation includes the manifestations of a shift to the left in the WBC count, malaise, nausea, anorexia, increased pulse and respiratory rate, and fever. The local response to inflammation includes redness, heat, pain, swelling, or loss of function at the site of inflammation. There is not an infectious response to inflammation, only an inflammatory response to infection. The acute inflammatory response is a type of inflammation that heals in 2 to 3 weeks and usually leaves no residual damage.

A nurse is obtaining a health history from a patient with a new diagnosis of type 2 diabetes mellitus. What question related to the skin would be most important for the nurse to ask this patient? a. "Is your sleep interrupted by severe episodes of itching at night?" b. "Have you noticed any changes in the way sores or wounds heal?" c. "Do you have any skin lesions that have changed in size or shape?" d. "What changes if any have you noticed in your skin, hair, and nails?"

b. "Have you noticed any changes in the way sores or wounds heal?" A patient with diabetes is more susceptible to poor wound healing because of the macrovascular and microvascular changes that occur in diabetes. Poor circulation, especially in the lower extremities, increases the risk for poor wound healing. A patient with diabetes is at increased risk for infection because of a defect in the mobilization of inflammatory cells and an impairment of phagocytosis by neutrophils and monocytes.

The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate which of the following signs in the client? a. coma b. flushing c. dizziness d. tachycardia

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

A patient in the unit has a 103.7 degree temperature. Which intervention would be most effective in restoring normal body temperature? a. Use a cooling blanket while the patient is febrile. b. Administer antipyretics on around-the-clock schedule. c. Provide increased fluids and have the UAP give sponge baths. d. Give prescribed antibiotics and provide warm blankets for comfort.

b. Administer antipyretics on around-the-clock schedule.

The nurse is performing an assessment of a patient with obesity. Inspection reveals the presence of a foul odor that emanates from the patient's abdominal skin folds. What is most likely causing the odor? a. Ecchymosis b. Colonization by yeast or bacteria c. Age-related integumentary changes d. Atrophy of the skin under the abdominal folds

b. Colonization by yeast or bacteria Unusual foul odors, especially those found in intertriginous areas, are often the result of colonization by yeast or bacteria. Ecchymosis is the presence of bruising. An unusual odor would not normally be attributed to age-related changes or skin atrophy.

The nurse is administering medications to a patient. What medication taken by the patient is most likely to have an effect on the integumentary system? a. Diuretic b. Corticosteroid c. Benzodiazepine d. Calcium channel blocker

b. Corticosteroid Corticosteroids can have unwanted integumentary side effects such as telangiectasia. Integumentary effects are less likely to occur with benzodiazepines, calcium channel blockers, and diuretics.

A nurse is caring for a patient with diabetes who is scheduled for amputation of his necrotic left great toe. The patient's WBC count is 15.0 x 10^6/uL, and he has coolness of the lower extremities, weight 75lb more than his ideal body weight, and smoke two packs of cigarettes per day. Which priority nursing diagnosis addresses the primary factor affecting the patient's ability to heal? a. Imbalanced nutrition: more than body requirements related to high fat foods b. Impaired tissue integrity related to decreased blood flow secondary to diabetes and smoking c. Ineffective peripheral tissue perfusion related to narrowed blood vessels secondary to diabetes and smoking d. Ineffective individual coping related to indifference and denial of the long-term effects of diabetes and smoking

b. Impaired tissue integrity related to decreased blood flow secondary to diabetes and smoking

The patient has diffuse distribution of moles on the body and the nurse is preparing the patient for a punch biopsy of one of the moles. What is the benefit of doing a punch biopsy for this patient? a. It is used for a superficial lesion. b. It provides a full-thickness of skin. c. It is used for good cosmetic results. d. It is used because the lesion is too large to remove.

b. It provides a full-thickness of skin. The punch biopsy provides full-thickness skin for diagnostic purposes. A shave biopsy is used for a superficial lesion or when only a small sample is needed for diagnostic purposes. An excisional biopsy is used when a good cosmetic result is desired. An incisional biopsy is a wedge-shaped incision made in a lesion that is too large for an excisional biopsy. It is useful when a larger specimen is needed than a shave or punch biopsy can provide.

The nurse is conducting an integumentary assessment of an African American patient who has darkly pigmented skin and a history of chronic obstructive pulmonary disease (COPD). Which locations should the nurse inspect for cyanosis (select all that apply.)? Select all that apply. a. Patient's sclera b. Patient's nail beds c. Soles of the patient's feet d. Palms of the patient's hands e. Conjunctiva of the patient's eyes

b. Patient's nail beds e. Conjunctiva of the patient's eyes In patients with darkly pigmented skin, the conjunctiva and nail beds are often examined to assess for cyanosis. The palms of the hands, soles of the feet, and the sclera are not the focus when assessing for cyanosis.

A patient 1 day postoperative after abdominal surgery has incisional pain, 99.5 degree temperature, slight erythema at the incision margins, and 30 mL serosanguineous drainage in the Jackson-Pratt drain. Based on this assessment, what conclusion would the nurse make? a. The abdominal incision shows signs of an infection. b. The patient is having a normal inflammatory response. c. The abdominal incision shows signs of impending dehiscence. d. The patient's physician needs to be notified about her condition.

b. The patient is having a normal inflammatory response.

The nurse assessing a patient with a chronic leg wound finds local signs of erythema and pain at the wound site. What would the nurse anticipate being ordered to assess the patient's systemic response? a. Serum protein analysis b. WBC count and differential c. Punch biopsy of center of wound d. Culture and sensitivity of the wound

b. WBC count and differential

On assessment, a linear crack from the epidermis to the dermis is noted at the corner of the patient's mouth. The nurse would document this finding as a(n) a. scar. b. fissure. c. atrophy. d. excoriation.

b. fissure. A fissure is a linear crack or break from the epidermis to the dermis. It can be dry as in athlete's foot or moist as in cracks at the corner of the mouth. A scar is abnormal formation of connective tissue that replaces normal skin when a wound heals. Atrophy is a depression in skin resulting from thinning of the epidermis or dermis. Excoriation is an area where epidermis is missing which exposes dermis (e.g., abrasion, scratch).

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

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

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

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

An older patient is transferred from the nursing home with a black wound on her heel. What should the nurse expect to be the first treatment of this wound? a) Dress it with an absorbent dressing for exudate. b) Handle the wound gently and let it dry out to heal. c) Debride the nonviable, eschar tissue to allow healing. d) Use negative-pressure wound (vacuum) therapy to facilitate healing.

c) Debride the nonviable, eschar tissue to allow healing. With a black wound the immediate therapy should be debridement (surgical, mechanical, autolytic, or enzymatic) to prepare the wound bed for healing. Black wounds may have purulent drainage, but debridement is done first. The red wound is handled gently because it is granulating and re-epithelializing, but it must be kept slightly moist to heal. The negative-pressure wound (vacuum) therapy is used to remove drainage and is more likely to be used after debridement.

The nurse determines that the patient may be suffering from an acute bacterial infection based upon which laboratory test result? a) Increased platelet count b) Increased blood urea nitrogen c) Increased number of band neutrophils d) Increased number of segmented myelocytes

c) Increased number of band neutrophils The finding of an increased number of band neutrophils in circulation is called a shift to the left, which is commonly found in patients with acute bacterial infections. Platelets increase with tissue damage through the inflammatory process and for healing but are not the best indicator of infection. Blood urea nitrogen is unrelated to infection unless it is in the kidney. Myelocytes increase with infection and mature to form band neutrophils, but they are not segmented. The mature neutrophils are segmented.

After the surgeon tells the patient that his wound will be allowed to heal by secondary intention, the patient asks the nurse what that is. How should the nurse explain this to the patient? a) The wound will be stapled together until it heals. b) The healing will contract the area to close the wound. c) The wound will be left open and heal from the edges inward. d) The wound will be sutured after the current infection is controlled.

c) The wound will be left open and heal from the edges inward. With secondary healing, the wound is left open and heals from the edges inward and from the bottom up. With primary intention, the wound edges are stapled or sutured, and healing occurs until the contraction of the healing area closes the defect and brings the skin edges closer together to form a mature scar. With tertiary healing, the contaminated wound is left open and closed after the infection is controlled.

When assessing a patient who is receiving cefazolin (Ancef) for the treatment of a bacterial infection, which data suggest that treatment has been effective? a) White blood cell (WBC) count 8000/μL, temperature 101○ F b) White blood cell (WBC) count 4000/μL, temperature 100○ F c) White blood cell (WBC) count 8500/μL, temperature 98.4○ F d) White blood cell (WBC) count 16,500/μL, temperature 98.8○ F

c) White blood cell (WBC) count 8500/μL, temperature 98.4○ F This response is correct because both the WBC count and the temperature are within the normal range. A normal WBC is 4000 to 11,000/μL. An elevated WBC count and elevated temperature are indicators of infection.

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

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

Which one of the orders should a nurse question in the plan of care for a patient with a stage III pressure ulcer? a. Pack the ulcer with foam dressing b. Turn and position the patient every 2 hours c. Clean the ulcer every shift with Dakin's solution d. Assess for pain and medicate before dressing change.

c. Clean the ulcer every shift with Dakin's solution

A patient is admitted to the acute care facility with purpura. Which laboratory test would be most important to check in the patient? a. Urinalysis b. Serum electrolytes c. Coagulation studies d. White blood cell count

c. Coagulation studies Purpura are areas of ecchymoses that may signify a bleeding disorder. Therefore, it is most important for the nurse to assess the patient's coagulation studies.

The nurse performs a physical assessment on a dark-skinned African American patient who reports difficulty breathing. What is the best location for the nurse to assess for cyanosis in this patient? a. Lips b. Earlobe c. Conjunctiva d. Palm of hand

c. Conjunctiva Cyanosis will appear ashen or gray color and is most easily seen in the conjunctiva of the eye, mucous membranes, and nail beds of dark-skinned individuals. The nail beds, earlobes, lips, mucous membranes, and palms and soles of feet would be appropriate locations to assess for cyanosis in a light-skinned individual.

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

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

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

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

A patient with diabetes mellitus has been diagnosed with peripheral vascular disease. Which dermatologic manifestations should the nurse assess? a. Redness of exposed areas of the skin on the hand, foot, face, or neck b. Leathery, brownish skin on lower leg, pruritus, concave lesions with edema, scar tissue with healing c. Loss of hair in periphery, delayed capillary filling, dependent rubor, neuropathy, and delayed wound healing d. Atrophy, epidermal thinning, increased vascular fragility, impaired wound healing, thin loose dermis, and excess fat at the back of the neck

c. Loss of hair in periphery, delayed capillary filling, dependent rubor, neuropathy, and delayed wound healing A patient with diabetes mellitus and peripheral vascular disease is likely to have loss of peripheral hair, delayed capillary filling, dependent rubor, neuropathy, and delayed wound healing. A patient with a nicotinic acid (niacin) deficiency manifests redness of exposed areas of the skin on the hand or foot, face, or neck and infected dermatitis. A patient with venous ulcers will have leathery, brownish skin on the lower leg, pruritus, concave lesions with edema, and scar tissue with healing. A patient with glucocorticoid excess (Cushing syndrome) may have atrophy, epidermal thinning, increased vascular fragility, impaired wound healing, thin loose dermis, and excess fat at the back of the neck, clavicles, abdomen, and face.

When assessing an older adult patient, the nurse observed general wrinkles, sagging breasts, and tenting of the skin; gray hair; and thick brittle toenails. What age-related changes can cause these changes in the integumentary system? a. Decreased activity of apocrine and sebaceous glands, decreased density of hair, and increased keratin in nails b. Decreased extracellular water, surface lipids, and sebaceous gland activity; decreased scalp oil; and decreased circulation c. Muscle laxity, degeneration of elastic fibers, collagen stiffening, decreased melanin, and decreased peripheral blood supply d. Increased capillary fragility and permeability, cumulative androgen effect and decreasing estrogen levels, and decreased circulation

c. Muscle laxity, degeneration of elastic fibers, collagen stiffening, decreased melanin, and decreased peripheral blood supply The normal changes of aging include muscle laxity, degeneration of elastic fibers, and collagen stiffening that contribute to the wrinkles, sagging breasts, and tenting of the skin. Decreased melanin and melanocytes in the hair lead to gray hair, and decreased peripheral blood supply leads to thick brittle nails with diminished growth. Decreased apocrine and sebaceous glands would lead to dry skin with minimal to no perspiration and uneven skin color. Decreased density of hair leads to thinning and loss of hair. Increased keratin in nails leads to longitudinal ridging of the nails. The decreased extracellular water, surface lipids, and sebaceous gland activity lead to dry flaking skin. Decreased scalp oil leads to dry coarse hair and a scaly scalp, and decreased circulation leads to prolonged return of blood to nails on blanching. Increased capillary fragility and permeability in aging leads to bruising. A cumulative androgen effect and decreased estrogen levels lead to facial hirsutism in women and baldness in men. Decreased circulation leads to prolonged return of blood to nails on blanching.

The nurse is assessing a patient's skin temperature, turgor, moisture, and texture. What is the best technique for the nurse to use to obtain the data? a. Inspection of skin color b. Examination for vascularity c. Palpation of skin with the hand d. Percussion of the skin on the back

c. Palpation of skin with the hand Palpation of the skin with the back of the hand will assess temperature. Turgor is assessed by gently pinching the skin on the back of the hand and observing its return to original position when released. Moisture and texture of skin is assessed by touching it to assess it. Percussion does not assess the skin, but the organs beneath the skin.

An 82-year-old man is being cared for at home by his family. A pressure ulcer on his right buttock measures 1 X 2 X 0.8 cm in depth, and pink subcutaneous tissue is completely visible on the wound bed. Which stage would the nurse document on the wound assessment form? a. Stage I b. Stage II c. Stage III d. Stage IV

c. Stage III

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

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

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

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

The adult client was burned as a result of an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury? a. 18% b. 24% c. 36% d. 48%

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

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

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

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

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

A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50, a pulse of 110, and urine output of 20 mL over the past hour. The nurse reports the findings to the physician and anticipates which of the following prescriptions? a. transfusing 1 unit of packed red blood cells b. administering a diuretic to increase urine output c. increasing the amount of IV lactated Ringers solution administered per hour d. changing the IV lactated Ringer's solution to one that contains dextrose in water.

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

The nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which incorrect component of protective isolation technique? a. using sterile sheets and linens b. performing strict hand washing technique c. wearing gloves and gown only when giving direct care to the client d. wearing protective garb, including a mask, gloves, cap, shoe covers, gowns, and plastic apron

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

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

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

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

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

A nurse is teaching a patient how to promote healing following abdominal surgery. What should be included in the teaching (select all that apply)? a) Take the antibiotic until the wound feels better. b) Take the analgesic every day to promote adequate rest for healing. c) Be sure to wash hands after changing the dressing to avoid infection. d) Take in more fluid, protein, and vitamins C, B, and A to facilitate healing. e) Notify the health care provider of redness, swelling, and increased drainage.

d & e Fluid is needed to replace fluid from insensible loss and from exudates as well as the increased metabolic rate. Protein corrects the negative nitrogen balance that results from the increased metabolic rate and that needed for synthesis of immune factors and healing. Vitamin C helps synthesize capillaries and collagen. Vitamin B-complex facilitates metabolism. Vitamin A aids in epithelialization. The health care provider should be notified if there are signs of infection. If prophylactic antibiotics are prescribed, they must be taken until they are completely gone. Initially analgesics are taken throughout the day (e.g., every 3 to 4 hours) as needed. Infection must be avoided with aseptic procedures, including washing the hands before changing the dressing.

The patient previously had a breast reduction. She has come to the surgeon's office complaining about excess soft pink tissue where a scar should be forming. What complication of wound healing does the nurse recognize this to be? a) Adhesion b) Contractions c) Keloid formation d) Excess granulation tissue

d) Excess granulation tissue Excess granulation tissue, the excess soft pink tissue on the wound, is what this complication of wound healing is called. Adhesions are bands of scar tissue that form between or around organs. Wound contraction, which is a normal part of healing, is a complication when it results in deformity by shortening the tissue and impairing function. Keloid formation is a great protrusion of scar tissue that extends beyond the wound edges and may be uncomfortable.

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

d, c, a, b.

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

d.

The nurse is teaching a patient about diagnostic testing for allergic dermatitis. Which statement by the patient demonstrates a correct understanding of the teaching? a. "A blood test will confirm the presence of abnormal antibodies." b. "My skin cells will be stained and examined under the microscope." c. "The rash will be scraped with a razor blade and the flakes cultured." d. "I will return to have the substances removed and the areas evaluated."

d. "I will return to have the substances removed and the areas evaluated." A patch test is used to determine skin reactions to certain allergens applied to the skin. The patient will return in 48 to 72 hours for allergen removal and return again in 96 hours for evaluation.

A patient has been diagnosed with hypothyroidism. What should the nurse expect to assess in this patient's integumentary system? a. Warm, flushed skin; alopecia; thin nails b. General hyperpigmentation and loss of body hair c. Pale skin; pale mucous membranes; hair loss; nail dystrophy d. Cold, dry, pale skin; dry, coarse hair; brittle, slow-growing nails

d. Cold, dry, pale skin; dry, coarse hair; brittle, slow-growing nails With hypothyroidism, the patient will manifest with cold, dry, pale skin; dry, coarse, brittle hair; and brittle, slow-growing nails. With hyperthyroidism, the patient will have warm, flushed skin; alopecia with fine soft hair; and thin nails. With Addison's disease, the patient will have loss of body hair and generalized hyperpigmentation, especially in folds. With anemia, the patient will display pallor, pale mucous membranes, hair loss, and nail dystrophy.