Quiz #16 - Burns

a patient comes to the clinic to be treated for burns from a barbecue fire. although the patient does not appear to be in any respiratory distress, the nurse suspects an inhalation injury after observing which findings? SATA a. burns to the face b. bright cherry red color to lips c. singed nose hairs d. edema of the nasal septum e. black carbon particles around the mouth f. sweet, sugary smell to the breath

a. burns to the face c. singed nose hairs d. edema of the nasal septum e. black carbon particles around the mouth

an adult patient is admitted to the burn unit after being burned in a house fire. assessment reveals burns to the entire face, back of the head, and anterior torso and circumferential burns to both arms. using the rule of nines what is the extent of the burn injury? a. 18% b. 24% c. 45% d. 54%

c. 45%

A nurse is assessing a client with second degree burns. The shaded areas in the illustration indicate the parts of the body where the client sustained burns. Calculate the percentage fo the body that was burned using the Rule of Nines. Record your answer using one decimal place.

22.5%

The nurse is performing a sterile dressing change for a client who infected deep partial thickness burns of the chest and abdomen. list the steps in order in which each should be accomplished. a. apply sliver sulfadiazine ointment b. obtain specimens for aerobic and anaerobic wound cultures c. administer morphine sulfate 10mg IV d. debride the wound of eschar using gauze spongese. e. cover the wound with a sterile gauze dressing

3, 4, 2, 1, 5

A nurse is caring or a client who has a disturbed body image as a result of a burn injury. Which is an important nursing intervention for this client? A. Conveying a positive attitude toward the client B. Arranging for the client to meet other clients with burns C. Removing mirrors until the client's physical appearance has improved D. Reminding family members to avoid comments about the client's appearance

A. Conveying a positive attitude toward the client

A person on the beach sustains a deep partial-thickness burn because of a severe sunburn. What is the best first aid measure that a nurse should instruct the person to apply before seeking health care? A. Cool, moist towels B. Dry, sterile dressing C. Analgesic sunburn spray D. Vitamin A and D ointment

A. Cool, moist towels

A client with 35% of total body surface area burned in a fire is now 48 hours postburn. The nurse concludes that the client is moving from the emergent to the acute phase of burn management. Which response supports this conclusion? A. Hypokalemia B. Hypoglycemia C. Decreased blood pressure D. Increased urine specific gravity

A. Hypokalemia

Which is the most difficult problem for the nurse to manage when meeting the needs of an extensively burned client 3 days after admission? A. severe pain B. Maintenance of sterility C. Alteration in body image D. Frequent dressing changes

A. severe pain

A client is rescued from a burning building has partial and full thickness burns over 40% of the body. Which is the initial physiologic change that the nurse can expect? A. An increase in blood volume B. An increase in serum potassium C. A decrease in capillary permeability D. A decrease in urine specific gravity

B. An increase in serum potassium

Which information should the nurse include in a teaching plan for a client whose burns are being treated with the exposure method? A. Bathing will not be permitted B. Aseptic techniques are required C. Dressings will be changed every 3 days D. Room temperature must be kept at 72 degrees

B. Aseptic techniques are required

A severely burned client has been hospitalized for 2 days. Until now recovery has been uneventful, but the client begins to exhibit extreme restlessness. What does that nurse conclude the client is most likely developing? A. Kidney failure B. Fluid overload C. Cerebral hypoxia D. Metabolic acidosis

C. Cerebral hypoxia

A worker is involved in an explosion of a steam pipe and receives a scalding burn to the chest and arms. The burned areas are painful, mottled red, weeping and edematous. Which should the nurse conclude is an appropriate classification of these burns? A. Eschar B. Full-thickness C. Deep partial-thickness D. Superficial partial-thickness

C. Deep partial-thickness

A nurse is evaluating a client's fluid loss resulting from extensive burns. What is the most valuable blood test to use when monitoring a client's fluid loss? A. BUN B. blood pH C. Hematocrit D. Sedimentation rate

C. Hematocrit

A nurse is assessing a client during the first 24 hours after a burn injury. Which sign indicates to the nurse that fluid replacement therapy is adequate? A. Decreasing CVP readings B. Urinary output of 15-20 mL/hr C. Slowing of a previously rapid pulse D. Hematocrit level increasing from 50% to 55%

C. Slowing of a previously rapid pulse

A nurse is caring for a client who experienced serious burns in a fire. Which relationship between a client's burned body surface area and fluid loss should the nurse consider when evaluating fluid loss in a client with burns? A. Equal B. Unrelated C. Inversely related D. Directly proportional

D. Directly proportional

A nurse is caring for a client who sustained a partial thickness burn to the lower leg accounting for 5% of the total body surface area 1 day ago. A primary short-term outcome established by the nurse and client is "The client's: A. Airway will remain patent B. Burns will heal free of infection C. Urine output will exceed 30 mL every hour D. Pain will remain at 2 or less on a scale of 0 to 10

D. Pain will remain at 2 or less on a scale of 0 to 10

A nurse is caring for a client during the emergent phase of a severe burn injury. Which parenteral intervention prescribed by the health care provider should the nurse question? A. Colloids B. Potassium C. Hypertonic saline D. Lactated Ringer solution

B. Potassium

A nurse places a client with severe burns on a circulating air bed. What is the primary reason why the nurse implements this action? A. Increase mobility B. Prevent contractures C. Limit orthostatic hypotension D. Prevent pressure on peripheral blood vessels

D. Prevent pressure on peripheral blood vessels

the heath care provider has ordered an escharotomy for a patient because of constriction around the patients chest. the nurse is teaching the patent and family about the procedure. which statement by the family indicates a need for additional teaching? a. "he will have to receive general anesthesia" b. "he'll be awake for the procedure" c. "he will receive medication for sedation and pain" d. "we could stay with him at the bedside during the procedure"

a. "he will have to receive general anesthesia"

the nurse is monitoring the nutritional status of a burn patient. which indicators will the nurse use? sata a. amount of food the patient eats b. weight to height ratio c. serum albumin d. amount of water the patient drinks e. blood glucose f. serum potassium

a. amount of food the patient eats b. weight to height ratio c. serum albumin e. blood glucose

a patient has sustained a severe burn greater that 30% total body surface area (TBSA). what is the best way to assess renal function in this patient? a. measure urine output and compare this value with fluid intake b. weight the patient every day and compare that to the dry weight c. note the amount of edema and measure abdominal girth d. assist the patient with a urinal or bedpan every 2 hours

a. measure urine output and compare this value with fluid intake

the nursing student notes on the care plan that the burn patient she is caring for is at risk for organ ischemia. tased on the students knowledge of the pathophysiology of burns, which etiology does the nursing student select? a. related to hypovolemia and hypotension b. related to fluid overload and peripheral edema c. related to prolonged resuscitation and hypoxia d. related to direct blunt trauma to the kidneys

a. related to hypovolemia and hypotension

the release of myoglobin from damaged muscle in patients with major burns can result in which potential complication? a. paralytic ileus b. acute kidney injury c. limited mobility d. hypovolemia

b. acute kidney injury

a patient has sustained a burn that appears red and moist. the nurse gently applies pressure to the area to assess for what sign/symptom? a. intensity of pain b. blanching c. pitting edema d. fluid-filled blisters

b. blanching

at what point does fluid mobilization occur in patients with burns? a. after the scar tissue is formed and fluid are no longer being lost b. within the first 4 hours after the burns were sustained c. about 24 hours after the burn injury when the fluid is reabsorbed from the interstitial tissue d. immediately after the burns occur

c. about 24 hours after the burn injury when the fluid is reabsorbed from the interstitial tissue

a patient was involved in a house fire and suffered extensive full thickness burns. in the long term, what issue may this patient have trouble with? a. intolerance for vitamin C b. metabolism of vitamin K c. activation of vitamin D d. absorption of vitamin A

c. activation of vitamin D

a patient was admitted for burns to the upper extremities after being rapped in a burning structure. the patient is also at risk for inadequate oxygenation related to inhalation of smoke and superheated fumes. which diagnostic test best monitors this patients gas exchange? a. complete blood count b. myoglobin level c. carboxyhemoglobin level d. chest x ray

c. carboxyhemoglobin level

which drug therapy reduces the risk of wound infection for burn patients? a. large doses of oral anti fungal medications every 4 hours b. silver nitrate solution covered by dry dressings applied every 4 hours c. silver sulfadiazine on full-thickness injuries every 4 hours d. broad-spectrum antibiotics given intravenously

c. silver sulfadiazine on full-thickness injuries every 4 hours

The nurse is caring for a patient who has 30% total body surface area (TBSA) burn. during the first 12-36 hours, the nurse carefully monitors the patient for which status changes related to capillary leak syndrome? a. bradycardia and pitting edema b. hypertension and increased urine output c. tachycardia and hypotension d. respiratory depression and lung crackles

c. tachycardia and hypotension

the nurse is performing a morning assessment on a patient admitted for serious burns to the extremities. for what reason does the nurse assess the patients abdomen? a. to perform a daily full head to toe assessment b. to assess for nausea and vomiting related to pain medication c. to assess for a paralytic ileum secondary to reduced blood flow d. to monitor increased motility that may result in cramps and diarrhea

c. to assess for a paralytic ileum secondary to reduced blood flow

the nurse is caring for several patients on the burn unit. which of these patients has the most acute need for cardiac monitoring? a. older adult woman who spilled hot water over her legs while boiling noodles b. teenager with facial burns that occurred when he threw gasoline on a campfire c. young woman who was struck by lightning while jogging on the beach d. middle aged man who fell asleep while smoking and sustained burns to the chest

c. young woman who was struck by lightning while jogging on the beach

The nurse has just received a change of shift report for the burn unit. which client should be assessed first? a. client with deep partial thickness burns on both legs who reports severe and continuous leg pain b. client who has just arrived from the emergency department with facial burns sustained in a house fire c. client who has just been transferred from the post anesthesia care unity after having skin grafts applied to the anterior chest d. client admitted 3 weeks ago with full thickness leg and buttock burns who has been waiting for 3 hours to receive discharge teaching

d. client admitted 3 weeks ago with full thickness leg and buttock burns who has been waiting for 3 hours to receive discharge teaching

a patient who sustained severe burns to the face with significant scarring and disfigurement will soon be discharged from the hospital. which intervention is best to help the patient make the transition into the community? a. discuss cosmetic surgery that could occur over the next several years b. focus on the positive aspects of going home and being with family c. teach the family to perform all aspects of care for the patient d. encourage visits from friends and short public appearances before discharge

d. encourage visits from friends and short public appearances before discharge

a burn patient refuses to eat. the potential problem of weight loss r/t increased metabolic rate and reduced calorie intake is identified for this patient. what method does the nurse use to weigh this patient correctly? a. weigh once a week after morning hygiene and compare to previous weight b. weigh daily at the same time of day and compare to preburn weight c. use a bed scale and subtract the estimated weight of linens d. weigh daily without dressings or splints and compare to preburn weight

d. weigh daily without dressings or splints and compare to preburn weight

a patient sustained a superficial thickness burn over a large area of the body. the patient is crying with discomfort and is very concerned about the long term effects. what does the nurse tell the patient to expect? a. "healing should occur in 3-6 days with no scarring or complications" b. "the pain should be less because more of the nerve endings were destroyed" c. "the wound will appear red and dry with some white areas" d. "the leathery eschar will have to be removed before healing can occur"

a. "healing should occur in 3-6 days with no scarring or complications"

The priority expected outcome during the resuscitation phase of a burn injury is to maintain which factor? a. the airway b. cardiac output c. fluid replacement d. patient comfort

a. the airway

the nurse observes peeling of dead skin on the legs of a patient with superficial thickness burn wound. what is the most accurate description of this assessment finding? a. blanching b. desquamation c. slough d. fluid shift

b. desquamation

the nurse is caring for several patients on the burn unit who have sustained extensive tissue damage. the nurse should monitor for which electrolyte imbalance that is typically associated with the initial third-spacing fluid shift? a. hypercalcemia b. hypernatremia c. hypokalemia d. hyperkalemia

d. hyperkalemia

A nurse is caring for a client during the first few hours after admission to the burn unit with partial thickness burns of the trunk and head. Which potential problem is the last concern for the nurse during the emergent phase of a burn injury? A. Pain B. Leukopenia C. Laryngeal edema D. Fluid volume deficit

B. Leukopenia

A person who sustains deep partial-thickness burns while working on a boat in a town marina and seeks advice from the nurse in the first aid station. The nurse encourages the client to seek medical attention, but the client refuses. The nurse advises the person to go to a health care provider if: A. Blisters appear B. Urinary output decreases C. Edema and redness occur D. Low grade fever develops

B. Urinary output decreases

Which client is best for the nurse manager on the burn unit to assign to an RN who has floated from the oncology unit? A. a 23 year old client who has just been admitted with burns over 30% of the body after a warehouse fire B. a 36 year old client who requires discharge teaching about nutrition and would care after having skin grafts C. a 45 year old client with infected partial thickness back and chest burns who has a dressing change scheduled D. a 57 year old client with full thickness burns on both arms who needs assistance in positioning hand splints

C. a 45 year old client with infected partial thickness back and chest burns who has a dressing change scheduled

The nurse has just received the change of shift report in the burn unit. which client requires the most immediate assessment or intervention? A. a 22 year old client admitted 4 days previously with facial burns due to a house fire who has been crying since recent visitors left B. a 34 year old client who returned from skin graft surgery 3 hours ago and is reporting level 8 pain (0-10 scale) C. a 45 year old client with partial thickness leg burns who has a temperature of 102.6F (39.2C) and a blood pressure of 98/46mmHg D. a 57 year old client who was admitted with electrical burns 24 hours ago and has a blood potassium level of 5.1 mEq/L

C. a 45 year old client with partial thickness leg burns who has a temperature of 102.6F (39.2C) and a blood pressure of 98/46mmHg

a patient who lives in a rural community sustained severe burns during a house fire at 10am. the rural emergency medical services (EMS) started a peripheral IV at 1100 am at a keep-vein-open (KVO) rate. the patient was admitted to the hospital at 1:00pm. in calculating the fluid replacement, at what time is the fluid for the first 8 hour period completed? a. 6:00pm b. 7:00pm c. 8:00pm d. 9:00pm

a. 6:00pm

a 28-year-old male patient sustained second and third-degree burns on his legs (30%) when his clothing caught fire while he was burning leaves. he was hosed down by his neighbor and arrived at the ED in severe discomfort. what is the priority problem for the patient at this time? a. acute pain r/t damaged or exposed nerve endings b. decreased fluid volume r/t electrolyte imbalance c. potential for inadequate oxygenation d. diminished self-image r/t the appearance of legs

a. acute pain r/t damaged or exposed nerve endings

the nurse is changing a burn patients dressing. which factors would affect the number of gauze layers applied after a topical agent has been used to treat the wound? sata a. amount of drainage b. patient mobility c. amount of pain d. depth of injury e. positioning of patient f. frequency of dressing changes

a. amount of drainage b. patient mobility d. depth of injury f. frequency of dressing changes

the nurse is applying a dressing to cover a burn on a patients left leg. what technique does the nurse use? a. consider the depth of the injury and amount of drainage, and work distal to proximal b. change the dressing every 4 hours or when the drainage leaks through the dressing c. consider the patients mobility and the area of injury, and work proximal to distal d. use multiple gauze layers and roller gauze to pad and protect the joint areas

a. consider the depth of the injury and amount of drainage, and work distal to proximal

the nurse is caring for several patients on the burn unit. which patients have the greatest risk for developing respiratory problems? SATA a. patient who was in a storage room where chemicals caught fire b. patient who was workin gin an area where steam escaped from a pipe c. patient who sustained a circumferential burn to the chest area d. patient who was burned when a firecracker exploded prematurely e. patient who was found unconscious in a slow burning house fire f. patient whose clothes caught fire while burning leaves

a. patient who was in a storage room where chemicals caught fire b. patient who was workin gin an area where steam escaped from a pipe c. patient who sustained a circumferential burn to the chest area e. patient who was found unconscious in a slow burning house fire

The nurse is caring for a patient with 45% total body surface area (TBSA) burns. which are priority medical surgical concepts for this patient? sata a. tissue integrity b. cellular regulation c. perfusion d. elimination e. fluid and electrolyte balance f. gas exchange

a. tissue integrity c. perfusion e. fluid and electrolyte balance

several patients are transported from an industrial fire to a local emergency department (ED). which factors increase the risk of death for these patients? sata a. male gender b. age greater than 60 years c. burn greater than 40% TBSA d. presence of an inhalation injury e. presence of contact burns f. history of kidney disease

b. age greater than 60 years c. burn greater than 40% TBSA d. presence of an inhalation injury

the nurse is caring for several patients who have sustained burns. the patient with which initial injury is the least likely to experience severe pain when a sharp stimulus is applied? a. severe sunburn after lying in the sun for several hours b. deep full thickness burn from an electrical accident c. partial thickness burn from picking up a hot pan d. deep partial thickness burn after a motorcycle accident

b. deep full thickness burn from an electrical accident

Because of fluid shifts in burn patients, what effects on cardiac output does the nurse expect to see? a. an initial increase, then normalized in 24-48 hours b. depressed up to 36 hours after the burn c. improved with fluid restrictions d. responsive to diuretics as evidenced by urinary output

b. depressed up to 36 hours after the burn

the nurse is caring for a young woman who sustained burns on the upper extremities and anterior chest while attempting to put out a kitchen grease fire. which laboratory results does the nurse expect to see during the resuscitation phase? sata a. potassium level of 3.2 mEq/L b. glucose level of 180 mg/dL c. hematocrit of 49% d. pH of 7.20 e. sodium level of 139 mEq/L f. albumin level of 2.9 g/dL

b. glucose level of 180 mg/dL c. hematocrit of 49% d. pH of 7.20 f. albumin level of 2.9 g/dL

which statement about the third-spacing or capillary leak syndrome in a patient with severe burns is accurate? a. it usually happens in the first 36-48 hours b. it is a leak of plasma fluids into the interstitial space c. it is present only in the burned tissues d. it can usually be prevented with diuretics

b. it is a leak of plasma fluids into the interstitial space

the nurse is providing care for a burn patient who recently received a graft. on assessment of the patients wound, redness and swelling as well as some foul smelling drainage is noted. what does the nurse suspect? a. partial thickness burn b. local infection of burn wound c. failure of the graft d. systemic sepsis

b. local infection of burn wound

a patient with a burn injury had an autograft. the nurse learns in report that the donor site is on the upper thigh. what type of wound does the nurse expect to find at the donor site? a. stage 1 b. partial thickness c. full thickness d. stage 4

b. partial thickness

which feelings are most typically expressed by the burn patient? sata a. suspicion b. regression c. apathy d. denial e. suicidal ideation f. anger

b. regression d. denial f. anger

which vaccine is routinely administered when a burn patient is admitted to the hospital? a. hepatitis B b. tetanus c. influenza d. pneumonia

b. tetanus

which criteria describes a full thickness burn wound? SATA a. the wound is red, moist, and blanches easily b. there is destruction to the epidermis and dermis c. there are no skin cells for regrowth d. the burned tissue is avascular e. the burn wound will not be painful f. the burn wound has a dry, hard, leathery eschar

b. there is destruction to the epidermis and dermis c. there are no skin cells for regrowth d. the burned tissue is avascular f. the burn wound has a dry, hard, leathery eschar

the nurse has just received report on a patient admitted for steam inhalation burns. the patient is alert and conversant but reports that his throat feels raw. his wife says that he sounds harsh compared to usual. considering these findings, which order should the nurse question? a. continuous pulse oximetry b. vital signs and airway assessment twice a day c. intubation equipment at the bedside d. oxygen 2L via nasal cannula to maintain saturation of greater than 90%

b. vital signs and airway assessment twice a day

a burn patient must have pressure dressings applied to prevent contractors and reduce scarring. for maximum effective, what procedure pertaining to the pressure garments is implemented? a. changed every 24-48 hours to prevent infection b. worn at least 23 hours a day until the scar tissue matures c. removed for hygiene and during sleeping d. applied with aseptic technique

b. worn at least 23 hours a day until the scar tissue matures

the vasodilating effects of carbon monoxide in patients with carbon monoxide poisoning causes what clinical manifestation? a. cyanosis around the lips b. generalized pallor c. cherry-red skin color d. mottled skin color

c. cherry-red skin color

a burn patient with which condition is most likely to have mannitol (osmitrol) ordered as part of the drug therapy? a. peripheral edema associated with burns on the lower extremities b. inhalation burns around the mouth causing mucosal swelling c. electrical burn with myoglobin in the urine d. smoke inhalation and superficial burns to the forearms

c. electrical burn with myoglobin in the urine

which type of burn destroys the seat glands, resulting in decreased excretory ability? a. superficial b. partial thickness c. full thickness d. deep full thickness

c. full thickness

over a period of 4 days the patient developed an elevated temperature associated with disorientation and lethargy. lab values include a normal platelet level. which type of infection does the nurse suspect? a. viral b. fungal c. gram-positive bacterial d. gram-negative bacterial

c. gram-positive bacterial

a patient has sustained significant burns that have created a hyper metabolic state. in planning care for this patient, what does the nurse consider? a. increased retention of sodium b. decreased secretion of catecholamines c. increased caloric needs d. the decrease in core temperature

c. increased caloric needs

the nurse is caring for a patient who sustained carbon monoxide poisoning. what assessment finding does the nurse anticipate? a. patient will be cyanotic because of hypoxia b. blood gas value of Pao2 will be very low c. patient will report a headache d. patient will report a dry and irritated throat

c. patient will report a headache