BURN BABY BURN. You don't want no Trauma no no no trauma

Using the Parkland formula, an 85-kg patient with a 35% total body surface area (TBSA) burn is to receive a total of 5950 mL of fluid resuscitation within the first 24 hours after injury. How much of this total volume will the patient receive in the first 8 hours of fluid resuscitation? A. 2975 mL B. 1983 mL C. 3966 mL D. 1488 mL

A. 2975 mL According to the Parkland formula, half of the calculated amount of fluid is administered to the patient in the first 8 hours after injury, 25% is given in the second 8 hours, and 25% is given in the third 8 hours.

10. A patient has been admitted with septic shock due to urinary sepsis. The practitioner inserts a pulmonary artery (PA) catheter. Which hemodynamic value would the nurse expect to note to support this diagnosis? a. Cardiac output (CO) of 8 L/min b. Right atrial pressure (RAP) of 17 mm Hg c. Pulmonary artery occlusion pressure (PAOP) of 23 mm Hg d. Systemic vascular resistance (SVR) of 1100 dyne/s/cm-5

ANS: A Increased cardiac output and decreased systemic vascular resistance are classic signs of septic shock.

What are the goals of the rehabilitation phase of burn management? A. Recuperation and healing physically and emotionally B. Hydrotherapy and splinting C. Reverse wound isolation and surgical grafting D. Bed rest and splinting

ANS: A. Recuperation and healing physically and emotionally The rehabilitation phase is one of recuperation and healing physically and emotionally.

According to the American College of Surgeons, burns to which body surfaces are best treated in a burn center? (Select all that apply.) A. Arms B. Perineum C. Chest D. Genitalia E. Face

ANS: B, D, E Perineum, Genitalia, Face According to triage criteria from the American College of Surgeons, burns on the face, hands, feet, genitalia, major joints, and perineum are best treated in a burn center.

What is a leading cause of death in the hospitalized burn patient? a. Smoke inhalation b. Infection c. Burn shock d. Renal failure

ANS: B. Infection Preventing infection in burn patients is a true challenge and involves complex decision making. Considerable debate has been going on about the infection control precautions to use with burn patients. The burn wound is the most common source of infection in burn patients.

A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding will the nurse expect next? a. Skin flushing b. Muscle cramps c. Rising body temperature d. Decreasing blood pressure

ANS: C The patient's complaints of feeling cold and shivering indicate that the hypothalamic set point for temperature has been increased and the temperature is increasing. Because associated peripheral vasoconstriction and sympathetic nervous system stimulation will occur, skin flushing and hypotension are not expected. Muscle cramps are not expected with chills and shivering or with a rising temperature.

A patient has developed septic shock. The nurse knows that the patient is at risk for gastrointestinal dysfunction. What happens to the gastrointestinal tract in the patient with septic shock? a. Anorexia leads to loss of gastric enzymes b. Lack of food ingestion leads to intestinal hypomotility c. Hypoperfusion results in loss of gut barrier function d. Low cardiac output causes decreased hydrochloric acid secretion

ANS: C With microcirculatory failure to the gastrointestinal tract, the gut's barrier function may be lost, which leads to bacterial translocation, sustained inflammation, endogenous endotoxemia, and multiple-organ dysfunction syndrome (MODS).

What parameter is used instead of the Parkland formula to assess fluid resuscitation in the patient with electrical burns? A. Serum creatinine B. Hemoglobin/hematocrit C. Central venous pressure D. Urine output

D. Urine output Fluid resuscitation for an electrical burn patient does not correlate with the Parkland formula, and the fluid is adjusted according to the patient's urine output. If myoglobin is present in the urine, a urine output greater than 100 mL/h in adults and 2 mL/kg/h in children is established until the urine is clear of all myoglobin pigment.

An unresponsive trauma patient has been admitted to the emergency department. Which statement regarding opening the airway is accurate? a.Airway assessment must incorporate cervical spine immobilization. b.Hyperextension of the neck is the only acceptable technique. c.Flexion of the neck protects the patient from further injury. d.Airway patency takes priority over cervical spine immobilization.

ANS: A Airway assessment must incorporate cervical spine immobilization. The patient's head should not be rotated, hyper-flexed, or hyperextended to establish and maintain an airway. The cervical spine must be immobilized in all trauma patients until a cervical spinal cord injury has been definitively ruled out.

A patient with multisystem trauma has been in the intensive care unit (ICU) for 6 days. The patient is still intubated and mechanically ventilated and has a chest tube, urinary drainage catheter, nasogastric tube, and two abdominal drains. The patient's vital signs include blood pressure (BP), 92/66 mm Hg; heart rate (HR), 118 beats/min; temperature (T), 38.7° C; and central venous pressure (CVP), 5 mm Hg. What is the most likely cause of this hemodynamic picture? a.Septic shock b.Hemorrhagic shock c.Cardiogenic shock d.Neurogenic shock

ANS: A The patient with multiple injuries is at risk for overwhelming infections and sepsis. The source of sepsis in the trauma patient can be invasive therapeutic and diagnostic catheters or wound contamination with exogenous or endogenous bacteria. The source of the septic nidus must be promptly evaluated. Gram stain and cultures of blood, urine, sputum, invasive catheters, and wounds are obtained.

A patient is being admitted with septic shock. The nurse appreciates that the key to treatment is finding the cause of the infection. Which cultures would the nurse obtain before initiating antibiotic therapy? (Select all that apply.) a. Blood cultures 2 b. Wound cultures c. Urine cultures d. Sputum cultures e. Complete blood count (CBC) with differential

ANS: A, B, C, D A key measure in the treatment of septic shock is finding and eradicating the cause of the infection. At least two blood cultures plus urine, sputum, and wound cultures should be obtained to find the location of the infection before antibiotic therapy is initiated. Antibiotic therapy should be started within 1 hour of recognition of severe sepsis without delay for cultures.

Identify in the correct order the five layers of the skin from the surface inward. 1. Stratum granulosum 2. Stratum corneum 3. Stratum germinativum 4. Stratum lucidum 5. Stratum spinosum A. 2, 4, 1, 5, 3 B. 2, 4, 5, 1, 3 C. 4, 2, 5, 1, 3 D. 4, 5, 1, 3, 2

ANS: A. 2, 4, 1, 5, 3 From the surface inward, its five layers are the(2) stratum corneum,(4) stratum lucidum,(1) stratum granulosum,(5) stratum spinosum,and (3) stratum germinativum.

Contracture development leading to impaired physical mobility can occur after a major burn injury. Splints are applied to prevent or correct contractures. Priority nursing interventions concerning this therapy include which action? A. Daily assessment for proper fit and effectiveness B. Removal of splints during showers and dressing changes C. Allowing for frequent breaks from splint use D. Passive and active range of motion may be used instead of splints

ANS: A. Daily assessment for proper fit and effectiveness Splints can be used to prevent or correct contracture or to immobilize joints after grafting. If splints are used, they must be checked daily for proper fit and effectiveness. Splints that are used to immobilize body parts after grafting must be left on at all times, except to assess the graft site for pressure points during every shift. Splints to correct severe contracture may be off for 2 hours per shift to allow burn care and range-of-motion exercises.

A patient is admitted to the burn unit after a house fire. The patient sustained extensive burns to the chest, back, left arm, right arm, right upper leg, and areas on the face. The nurse is unable to obtain a palpable pulse or a Doppler pulse in the right arm. What procedure should the nurse anticipate next? A. Escharotomy B. Silver sulfadiazine application C. Splint application D. Xenograft application

ANS: A. Escharotomy An escharotomy may be required to restore arterial circulation and to allow for further swelling. The escharotomy can be performed at the bedside with a sterile field and scalpel.

A patient is brought to the emergency department with extensive burns after a house fire. What is an important nursing intervention for this patient during the resuscitation phase? A. Intravenous opiates and assessment of pulses in both arms B. Oral anti-inflammatory drugs and preparation for insertion of an arterial line C. Measurement of sedimentation rate and systemic antibiotics D. Application of splints and initiation of total parenteral nutrition

ANS: A. Intravenous opiates and assessment of pulses in both arms Pain management in burn injuries must be addressed early and frequently reassessed to determine the adequacy of interventions. Intravenous opiates, such as morphine sulfate, are indicated and titrated to effect. Edema formation may cause neurovascular compromise to the extremities; assessments are necessary to evaluate pulses, skin color, capillary refill, and sensation.

1. A nurse is discussing the concept of shock with a new graduate nurse. Which statement indicates the new graduate nurse understood the information? a. Shock is a physiologic state resulting in hypotension and tachycardia. b. Shock is an acute, widespread process of inadequate tissue perfusion. c. Shock is a degenerative condition leading to organ failure and death. d. Shock is a condition occurring with hypovolemia that results in hypotension.

ANS: B Shock is an acute, widespread process of impaired tissue perfusion that results in cellular, metabolic, and hemodynamic alterations. It is a complex pathophysiologic process that often results in multiple-organ dysfunction syndrome and death. All types of shock eventually result in ineffective tissue perfusion and the development of acute circulatory failure.

The nurse assesses a patient's surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is appropriate? a. Obtain wound cultures. b. Document the assessment. c. Notify the health care provider. d. Assess the wound every 2 hours.

ANS: B The incisional redness and warmth are indicators of the normal initial (inflammatory) stage of wound healing by primary intention. The nurse should document the wound appearance and continue to monitor the wound. Notification of the health care provider, assessment every 2 hours, and obtaining wound cultures are not indicated because the healing is progressing normally.

A patient is brought to the emergency department after a house fire. He fell asleep with a lit cigarette, and the couch ignited. What is the nurse's first priority? A. Clean the wounds and remove blisters. B. Assess the airway and provide 100% oxygen. C. Place a urinary drainage catheter and assess for myoglobin. D. Place a central intravenous access and provide antibiotics

ANS: B Assess the airway and provide 100% oxygen. The first priority of emergency burn care is to secure and protect the airway. All patients with major burns or suspected inhalation injury are initially administered 100% oxygen.

A patient is admitted after being burned while lighting the barbecue. The injuries appear moist and red with some blister formation and the patient states they are very painful. What kind of burn would the nurse document in the patient's record? A. Superficial, first-degree burn B. Partial-thickness, second-degree burn C. Deep dermal partial-thickness, second-degree burn D. Full-thickness, third-degree burn

ANS: B. Partial-thickness, second-degree burnA light to bright red or mottled appearance characterizes superficial second-degree burns. These wounds may appear wet and weeping, may contain bullae, and are extremely painful and sensitive to air currents. The microvessels that perfuse this area are injured, and permeability is increased, resulting in leakage of large amounts of plasma into the interstitium. This fluid, in turn, lifts off the thin damaged epidermis, causing blister formation. Despite the loss of the entire basal layer of the epidermis, a burn of this depth will heal in 7 to 21 days.

Using the "rule of nines," calculate the percent of injury in an adult who was injured as follows: the patient sustained partial and full-thickness burns to half of his left arm, his entire left leg, and his perineum. a. 28% b. 23.5% c. 45.5% d. 16%

ANS: B. 23.5% The arm represents 4.5%, the leg 18%, and the perineum 1%, totaling 23.5%.

A patient with multisystem trauma has been in the critical care unit for 2 days. The patient is still intubated and mechanically ventilated and has a chest tube, urinary drainage catheter, nasogastric tube, and two abdominal drains. The nurse understands that immobility places the patient at risk for developing which complication? a.Pneumonia b.Infection c.Venous thromboembolism d.Fat embolism syndrome

ANS: C BUT THIS CLEARLY SAYS INFECTION IS CORRECT, RIGHT? Trauma patients are at risk for infection because of contaminated wounds, invasive therapeutic and diagnostic catheters, intubation and mechanical ventilation, host susceptibility, and the critical care environment. Nursing management must include interventions to decrease and eliminate the trauma patient's risk of infection.

A patient is admitted after being burned in a car fire. The wound surface is red with patchy white areas that blanch with pressure but no blister formation. What kind of burn would the nurse document in the patient's record? A. Superficial partial-thickness burn B. Moderate partial-thickness burn C. Deep dermal partial-thickness burn D. Full-thickness burn

ANS: C. Deep dermal partial-thickness burn Deep-dermal partial-thickness (second-degree) burns involve the entire epidermal layer and deeper layers of the dermis. A deep-dermal partial-thickness burn usually is not characterized by blister formation. Only a modest plasma surface leakage occurs because of severe impairment in blood supply. The wound surface usually is red with patchy white areas that blanch with pressure.

A patient is admitted to the burn unit with extensive burns after a house fire. The patient's vital signs and physical exam include a heart rate of 140 beats/min, a urine output of 25 mL/h, and clear lung sounds. What adjustment, if any, needs to be made to the fluid resuscitation plan? A. Continue as planned; everything looks good. B. IV rate should be decreased and colloids started. C. IV rate should be increased and fluid status closely watched. D. Fluids should be switched to packed red blood cells.

ANS: C. IV rate should be increased and fluid status closely watched. Desired clinical responses to fluid resuscitation include a urinary output of 0.5 to 1 mL/ kg/h; a pulse rate lower than 120 beats/min; blood pressure in normal to high ranges; a central venous pressure less than 12 cm H2O or a pulmonary artery occlusion pressure less than 18 mm Hg; clear lung sounds; clear sensorium; and the absence of intestinal events, such as nausea and paralytic ileus.

What physiologic process can result in excessive burn edema and shock in a patient with injuries totaling more than 50% total body surface area (TBSA) burn? A. The heat from the burn leads to immediate vascular wall destruction and extravasation of intravascular fluid. B. A positive interstitial hydrostatic pressure occurs in the dermis leading to burn wound edema. C. Plasma colloid osmotic pressure is decreased because of protein leakage into the extravascular space. D. Capillary permeability decreases in burned and unburned tissue, leading to hypovolemia.

ANS: C. Plasma colloid osmotic pressure is decreased because of protein leakage into the extravascular space. Negative interstitial hydrostatic pressure represents an edema-generating mechanism and occurs for approximately 2 hours after injury. Additionally, plasma colloid osmotic pressure is decreased as a result of protein leakage into the extravascular space. Plasma is then further diluted with fluid resuscitation. Thus osmotic pressure is decreased and further fluid extravasation can occur.

A nurse is caring for a patient who was burned 2 weeks ago. The nurse knows the patient has entered the next phase of healing, which is characterized by rapid synthesis of collagen. What phase is the patient in? A. Wound phase B. Inflammatory phase C. Proliferative phase D. Maturation phase

ANS: C. Proliferative phase The proliferative phase of healing occurs approximately 4 to 20 days after injury. The key cell in this phase of healing, the fibroblast, rapidly synthesizes collagen. Collagen synthesis provides the needed strength for a healing wound. The inflammatory phase begins immediately after injury. Vascular changes and cellular activity characterize this period. Changes in the severed vessels occur in an attempt to wall off the wound from the external environment. The maturation phase, or remodeling phase, of healing occurs from approximately 20 days after injury to longer than 1 year after injury. During this period, the wound develops tensile strength as collagen deposits form scar tissue.

A patient involved in a house fire is brought by ambulance to the emergency department. The patient is breathing spontaneously but appears agitated and does not respond appropriately to questions. The nurse knows the patient has inhaled carbon monoxide and probably has carbon monoxide (CO) poisoning. What action should the nurse take next? A. Ask the practitioner to order a STAT chest radiograph. B. Apply a pulse oximeter to one of his unburned fingers. C. Call the local hyperbaric chamber to check on its availability. D. Administer 100% high-flow oxygen via a non-rebreathing mask.

ANS: D. Administer 100% high-flow oxygen via a non-rebreathing mask. The treatment of choice for carbon monoxide (CO) poisoning is high-flow oxygen administered at 100% through a tight-fitting non-rebreathing mask or endotracheal intubation. The half-life of CO in the body is 4 hours at room air (21% oxygen), 2 hours at 40% oxygen, and 40 to 60 minutes at 100% oxygen. The half-life of CO is 30 minutes in a hyperbaric oxygen chamber at three times the atmospheric pressure. Currently, the use of hyperbaric oxygen is of controversial benefit in care of burn patients.

The nurse and a new graduate nurse are caring for a patient with extensive burns. They are discussing skin grafts. Which statement indicates the new graduate understood the information? A. Autografts are procured from both live and deceased donors. B. Autografts can placed at the bedside or in the operating room. C. Autografts can transmit disease and be rejected. D. Autografts provide permanent coverage and are the least expensive.

ANS: D. Autografts provide permanent coverage and are the least expensive. An autograft is a skin graft harvested from a healthy, uninjured donor site on the burn patient and then placed over the patient's burn wound to provide permanent coverage of the wound. Autografts must be done in the operating room and are the least expensive. Homografts can transmit disease and be rejected.

Less than 24 hours ago a patient sustained full-thickness burns, to his face, chest, back, and bilateral upper arms, in a house fire. He also sustained an inhalation injury. The patient was intubated and ventilated and is now showing signs of increasing agitation and rising peak airway pressures. The nurse suspects the patient's change in condition is due to which problem? A. Uncontrolled pain B. Hypovolemia C. Worsening hypoxemia D. Decreased pulmonary compliance

ANS: D. Decreased pulmonary compliance Circumferential full-thickness burns to the chest wall can lead to restriction of chest wall expansion and decreased compliance. Decreased compliance requires higher ventilatory pressures to provide the patient with adequate tidal volumes.

Which topical antimicrobial agent is commonly used as a broad-spectrum and fights against gram-positive and -negative bacteria? A. Pure silver B. Bacitracin C. Mafenide acetate cream D. Silver sulfadiazine

ANS: D. Silver sulfadiazine Silver sulfadiazine (SSD; Silvadene cream) is a broad-spectrum antimicrobial agent with bactericidal action against many gram-negative and -positive bacteria associated with burn wound infection. Mafenide acetate cream penetrates through burn eschar and is bacteriostatic against many gram-negative and -positive organisms. Its use is limited because the application is uncomfortable for the patient because it creates a burning sensation, and it is rapidly absorbed, requiring dressing changes two or three times daily. It is used routinely for coverage of small wounds. Bacitracin ointment is a topical agent applied to superficial burns and facial burns. Bacitracin is effective against gram-positive organisms but not against gram-negative organisms or fungal organisms. Silver has long been used for the treatment of wounds because of its broad-spectrum bacteriostatic properties. The wound moisture activates the silver and releases it into the wound. Anadvantage of silver dressings is that the dressing does not need to be changed daily because of the sustained release of silver. Silver dressings should be used judiciously and limited to 4 to 6 weeks despite the current absence of negative systemic or local consequences.

A patient is admitted after being burned in a house fire. The nurse feels that the patient should be transferred to a burn center. Which factor is most important when determining whether or not to refer a patient to a burn center? A. The size and depth of burn injury and the burning agent B. The age and present medical history of the patient C. The depth of the burn injury and the presence of soot inthe sputum D. The medical history of the patient and the size and depth of the burn injury

ANS: D. The medical history of the patient and the size and depth of the burn injury Burns are classified primarily according to the size and depth of injury. However, the type and location of the burn and the patient's age and medical history are also significant considerations. Recognition of the magnitude of burn injury, which is based on the above-mentioned factors, is of crucial importance in the overall plan of care and in decisions concerning patient management and appropriate referral to a burn center.

What therapies may be administered to decrease oxygen demand in the patient with multiple-organ dysfunction syndrome? A. Antipyretics and sedative agents B. Diuretics and antidysrhythmic agents C. Crystalloids and antibiotics D. Vasoactive and positive inotropic agents

A. Antipyretics and sedative agents Oxygen demand can be decreased in any of the following ways: administering sedation or paralytics, administering antipyretics and external cooling measures, and administering pain medications. Vasoactives, positive inotropes, crystalloids, and antidysrhythmics are used to support oxygen transport, not decrease oxygen demand.

Which type of shock has the following hemodynamic manifestations: increased cardiac output (CO), increased cardiac index (CI), decreased right atrial pressure (RAP), decreased systemic vascular resistance (SVR), and decreased pulmonary artery occlusion pressure (PAOP)? A. Septic B. Cardiogenic C. Anaphylactic D. Neurogenic

A. Septic Clinical manifestations of septic shock include increased cardiac output (CO) and cardiac index (CI), decreased systemic vascular resistance (SVR), decreased right atrial pressure (RAP), and decreased pulmonary artery occlusion pressure (PAOP).

An elderly patient is admitted with pneumonia. This morning the patient is febrile, tachycardic, tachypneic, and confused. The nurse suspects the patient may be developing what problem? a. Sepsis b. Delirium c. Adult respiratory distress syndrome d. Acute kidney injury

ANS: A Increased heart rate, change in sensorium, increased temperature, and increased respiratory rate are all signs of sepsis in the presence of an existing infection.

3. A patient has been admitted with hypovolemic shock due to traumatic blood loss. Which nursing measure can best facilitate the administration of large volumes of fluid? a. Inserting a large-diameter peripheral intravenous catheter b. Positioning the patient in the Trendelenburg position c. Encouraging the patient to drink at least 240 mL of fluid each hour d. Administering intravenous fluids under pressure with a pressure bag

ANS: A Measures to facilitate the administration of volume replacement include insertion of large-bore peripheral intravenous catheters; rapid administration of prescribed fluids; and positioning the patient with the legs elevated, trunk flat, and head and shoulders above the chest.

The nurse is caring for a patient with extensive burns. Which zone of injury is the site of the most severe damage? A. Zone of coagulation B. Peripheral zone C. Zone of stasis D. Zone of hyperemia

ANS: A The central zone, or zone of coagulation, is the site of most severe damage, and the peripheral zone is the least. The central zone is usually the site of greatest heat transfer, leading to irreversible skin death.

A patient has been admitted with muscle trauma and crush injuries. The nurse understands that this patient is at high risk for the development of acute kidney injury secondary to rhabdomyolysis. Which findings would suggest the patient is developing this complication? (Select all that apply.) a.Dark tea-colored urine b.Decreased urine output c.Hypoxemia d.Diminished pulses e.Increased serum creatine kinase level

ANS: A, B, E Circulating myoglobin can lead to the development of kidney failure by three mechanisms: decreased renal perfusion, cast formation with tubular obstruction, and direct toxic effects of myoglobin in the kidney tubules. Dark tea-colored urine suggests myoglobinuria. The most rapid screening test is a serum creatine kinase level. Urine output and serial creatine kinase levels should be monitored. Hypoxemia and diminished pulses are not associated with rhabdomyolysis.

Patients immobilized because of spinal trauma are at a high risk for contractures. The nursing management plan for these patients should include which preventive measures? (Select all that apply.) a. Consultation by physical therapist (PT) and occupational therapist (OT) early in the treatment of the patient. b. Turning and repositioning the patient every 2 hours as ordered by the physician. c. Range of motion exercises 1 month after the spine has been stabilized. d. Removal of splints every 4 hours and at bedtime. e. Hand splints for patients with paraplegia. f. Hand and foot splints for patients with quadriplegia.

ANS: A, B, F Physical therapy and occupational therapy personnel should be consulted early in the patient's course. Range-of-motion exercises are initiated as soon as the spine has been stabilized. Footdrop splints should be applied on admission to prevent contractures and prevent skin breakdown of the heels. Hand splints should be applied for patients with quadriplegia. Hand and foot splints should be removed every 2 hours.

The nurse is caring for a patient with extensive trauma to the lower extremities. The nurse understands that patient is at risk for compartment syndrome. Which findings would the nurse expect to note as evidence of this complication? (Select all that apply.) a. Paresthesia b. Decreased pulses c. Pain in the affected extremity d. Swelling in the affected extremity e. Decreases capillary refill

ANS: A, C, D Clinical manifestations of compartment syndrome include obvious swelling and tightness of an extremity, paresis, and pain of the affected extremity. Diminished pulses and decreased capillary refill do not reliably identify compartment syndrome because they may be intact until after irreversible changes have occurred. Elevated intra-compartmental pressures confirm the diagnosis.

Major trauma patients are at high risk of developing deep venous thrombosis and pulmonary embolism. The nurse understands that trauma patients are at risk due to which factors? (Select all that apply.) a. Blood stasis b. Hypernatremia c. Injury to the intimal surface of the vessel d. Hyperosmolarity e. Hypercoagulopathy f. Immobility

ANS: A, C, E, F The factors that form the basis of venous thromboembolism (VTE) pathophysiology are blood stasis, injury to the intimal surface of the vessel, and hypercoagulopathy. Trauma patients are at risk for VTE because of endothelial injury, coagulopathy, and immobility. Hypernatremia and hyperosmolarity are associated with acute kidney injury.

A patient is brought to the emergency department after a house fire. He fell asleep with a lit cigarette, and the couch ignited. Total body surface area (TBSA) burn is estimated at 25% deep partial-thickness burns to areas of the chest, back, and left arm and 20% full-thickness burns to the right arm, right upper leg, and areas on the face. The patient's weight is estimated at 85 kg. What is the initial plan for fluid replacement? A. 5950 mL of Lactated Ringer (LR) solution for the first 8 hours; then 5950 mL of LR over the next 16 hours B. 2868 mL of normal saline (NS) for the first 8 hours; then 5737 mL of hypertonic NS over the next 16 hours C. 11,900 mL of dextran evenly divided over the first 24 hours D. 11,475 mL of LR evenly divided over the first 24 hours

ANS: A. 5950 mL of Lactated Ringer (LR) solution for the first 8 hours; then 5950 mL of LR over the next 16 hours Per the Parkland formula, you would administer 5950 mL of Lactated Ringer (LR) solution for the first 8 hours and 5950 mL of LR over the next 16 hours (4 mL × 85 kg × 45% = 15,300 mL in first 24 hours).

A patient is admitted to the burn unit after an electrocution. The patientsustained extensive burns. The nurse should have a high degree of suspicion for what complication associated with this type of burn injury? A. Rhabdomyolysis B. Stress ulcers C. Pneumothorax D. Venous thromboembolism

ANS: A. Rhabdomyolysis The electrical burn process can result in a profound alteration in acid-base balance and rhabdomyolysis, resulting in myoglobinuria, which poses a serious threat to renal function. Myoglobin is a normal constituent of muscle. With extensive muscle destruction, it is released into the circulatory system and filtered by the kidneys. It can be highly toxic and can lead to intrinsic renal failure.

The nurse is caring for a patient who what just admitted with septic shock. The nurse knows that certain interventions should be completed within 3 hours of time of presentation. Which intervention would be a priority for the nurse to implement upon receipt of a practitioner's order? a. Administer fresh frozen plasma b. Obtain a serum lactate level c. Administer epinephrine d. Measure central venous pressure

ANS: B According to the Surviving Sepsis Campaign Bundles, the following interventions should be completed within 3 hours of time of presentation 1. Measure lactate level. 2. Obtain blood cultures prior to administration of antibiotics. 3. Administer broad spectrum antibiotics. 4. Administer 30 mL/kg crystalloid for hypotension or lactate 4 mmol/L.

A patient has been admitted with septic shock related to tissue necrosis. The nurse knows the initial goal for medical management for this patient is which intervention? a. Limiting fluids to minimize the possibility of heart failure b. Finding and eradicating the cause of infection c. Discontinuing invasive monitoring as a possible cause of sepsis d. Administering vasodilator substances to increase blood flow to vital organs

ANS: B Effective treatment of severe sepsis and septic shock depends on timely recognition. The diagnosis of severe sepsis is based on the identification of three conditions: known or suspected infection, two or more of the clinical indications of the systemic inflammatory response, and evidence of at least one organ dysfunction. Clinical indications of systemic inflammatory response and sepsis were included in the original American College of Chest Physicians/Society of Critical Care Medicine consensus definitions.

A nursing instructor is discussing the difference between primary and secondary multiple-organ dysfunction syndrome (MODS) with a nursing student. Which statement indicates the student understood the information? a. Primary MODS is the result of inflammation in organs not involved in the initial insult. b. Primary MODS is the result of a direct organ injury. c. Primary MODS is due to a disorganization of the inflammatory immune system response. d. Primary MODS is due to disruption of the coagulation system.

ANS: B Organ dysfunction may be the direct consequence of an initial insult (primary multiple-organ dysfunction syndrome [MODS]) or can manifest latently and involve organs not directly affected in the initial insult (secondary MODS). Patients can experience both primary and secondary MODS. Primary MODS results from a well-defined insult in which organ dysfunction occurs early and is directly attributed to the insult itself.

1. A nurse is discussing the concept of shock with a new graduate nurse. Which statement indicates the new graduate nurse understood the information? a. Shock is a physiologic state resulting in hypotension and tachycardia. b. Shock is an acute, widespread process of inadequate tissue perfusion. c. Shock is a degenerative condition leading to organ failure and death. d. Shock is a condition occurring with hypovolemia that results in hypotension

ANS: B Shock is an acute, widespread process of impaired tissue perfusion that results in cellular, metabolic, and hemodynamic alterations. It is a complex pathophysiologic process that often results in multiple-organ dysfunction syndrome and death. All types of shock eventually result in ineffective tissue perfusion and the development of acute circulatory failure.

A patient is admitted with a blunt cardiac injury (BCI) with no evidence of rupture. The nursing management plan should include which intervention? a.Administer nitroglycerine for chest pain as needed. b.Monitor the patient for new onset dysrhythmias. c.Monitor serial biomarkers for evidence of further damage. d.Do not administer antidysrhythmic medications, as they are ineffective.

ANS: B The patient should be monitored for new onset of dysrhythmias. The patient may complain of chest pain that is similar to anginal pain, but it is not typically relieved with nitroglycerin. Chest pain is usually caused by associated injuries. Use of biomarkers, such as troponin, offers very little diagnostic help for blunt cardiac injury (BCI). Medical management is aimed at preventing and treating complications. This approach includes hemodynamic monitoring in a critical care unit and possible administration of antidysrhythmic medications.

Using the Parkland formula for fluid resuscitation and your knowledge of injury calculations using the "rule of nines," calculate the estimated fluid requirements during the first 8 hours for a 75-kg patient with full-thickness burns to the anterior chest, perineum, and entire right leg. A. 2775 mL B. 5550 mL C. 8325 mL D. 11,100 mL

ANS: B. 5550 ml In a 75-kg person with a 37% burn injury (based on a rule of nines calculation: 18%— chest, 1%—perineum, 18%—right leg = 37% total body surface area [TBSA] burn), the Parkland formula estimates fluid resuscitation needs at 4 mL × 37 × 75 = 11,100 mL. In the first 8 hours after injury, half of the calculated amount of fluid is administered. This amount equals 5550 mL.

A patient is brought to the emergency department after a house fire. The pt. sustained an inhalation injury. The nurse is aware that this injury predisposes the to the pt. development of what complication? A. Tension pneumothorax B. Adult respiratory distress syndrome (ARDS) C. Asthma D. Lung cancer

ANS: B. Adult respiratory distress syndrome (ARDS) Inhalation injury predisposes the patient to the development of pneumonia and acute respiratory distress syndrome (ARDS). Management of ARDS necessitates mechanical ventilatory support and, in extreme cases, high-frequency oscillatory ventilation or extracorporeal membrane oxygenation.

The nursing management plan for a patient with full-thickness burns includes which intervention? A. Daily replacement of autografts B. Daily wound care with premedication C. Weekly wound care until all eschar is debrided D. Surgical skin grafting within 8 hours of admission

ANS: B. Daily wound care with premedication Daily cleansing and inspection of the wound and unburned skin are performed to assess for signs of healing and local infection. Generally, this therapy is performed once or twice daily. Pain management and measures to reduce hypothermia are used. Patients should receive adequate premedication with analgesics and sedatives

The nurse understands that certain trauma patients are at risk for developing fat embolism syndrome. Which group of patients is a high risk for this complication? a.Patients with liver trauma b.Patients with burns c.Patients with orthopedic trauma d.Patients with spleen trauma

ANS: C Fat embolism syndrome can occur as a complication of orthopedic trauma.

Older trauma patients have a higher mortality than younger trauma patients. The nurse understands that this fact is probably related to what physiologic change? a.Deterioration of cerebral and motor skills b.Poor vision and hearing c.Diminished pain perception d.Limited physiologic reserve

ANS: D Older adults have limited ability to increase their heart rate in response to blood loss, obscuring one of the earliest signs of hypovolemia—tachycardia. Loss of physiologic reserve and the presence of preexisting medical conditions are likely to produce further conflicting hemodynamic data. An older patient's lack of physiologic reserve makes it imperative that early nutritional support is initiated.

A patient with extensive burns is undergoing skin grafting. The nurse understands pain control is best achieved with what strategies during the early phase of recovery? A. Large doses of opioids given intramuscularly B. Intravenous opioids used in combination with oral antidepressants C. Large doses of opioids given subcutaneously D. Small doses of intravenous opioids titrated to effect

ANS: D Initially after burn injury, narcotics are administered intravenously in small doses and titrated to effect. The constant background pain may be addressed with the use of a patient-controlled analgesia device. When hemodynamic stability has occurred and gastrointestinal function has returned, oral narcotics can be useful. Intramuscular or subcutaneous injections must not be administered because absorption by these routes is unpredictable because of the fluid shifts that occur with burn injury.

Roughly 80% of burns in children are classified as what type of burn? A. Radiation B. Chemical C. Electrical D. Thermal

ANS: D Thermal The most common type of burn is a thermal burn caused by steam, scalds, contact with heat, and fire injuries. About 80% of burns in children are caused by scalds (ie, contact with hot objects or liquids).

Roughly 80% of burns in children are classified as what type of burn? A. Radiation B. Chemical C. Electrical D. Thermal

ANS: D Thermal The most common type of burn is a thermal burn caused by steam, scalds, contact with heat, and fire injuries. About 80% of burns in children are caused by scalds (ie, contact with hot objects or liquids).

Which parameters are clinical manifestations of cardiogenic shock? A. Decreased right atrial pressure B. Decreased cardiac index to less than 2.2 L/min/m2 C. Decreased systemic vascular resistance D. Decreased pulmonary artery occlusion pressure

B. Decreased cardiac index to less than 2.2 L/min/m2 Initially, clinical manifestations reflect the decline in cardiac output. Clinical manifestations include cardiac index less than 2.2 L/min/m2, increased pulmonary artery occlusion pressure, increased right atrial pressure, and increased systemic vascular resistance.

A nurse is assigned a patient who has carbon monoxide (CO) poisoning. What is a priority nursing diagnosis for this patient? A. Ineffective airway clearance B. Impaired gas exchange C. Acute confusion D. Ineffective breathing pattern

B. Impaired gas exchange The most common pulmonary burn complication is carbon monoxide (CO) poisoning. The hemoglobin becomes fully saturated with CO and thus is unable to carry oxygen. The patient develops impaired gas exchange. There is no mention of problems with increased secretions or difficulty breathing at this time. Although the patient may manifest confusion, it is probably related to hypoxemia.

Which shock state includes hypotension despite adequate fluid resuscitation along with perfusion abnormalities such as lactic acidosis, oliguria, or acute change in mentation? A. Neurogenic B. Septic C. Anaphylactic D. Cardiogenic

B. Septic Septic shock includes hypotension despite adequate fluid resuscitation along with the presence of perfusion abnormalities that may include, but are not limited to, lactic acidosis, oliguria, or an acute alteration in mental status. Patients who are receiving inotropic or vasopressor agents may not be hypotensive at the time that perfusion abnormalities are measured. Neurogenic, anaphylactic, and cardiogenic shock are not refractory to fluid resuscitation.

A patient admitted after a house fire is starting to complain of hoarseness. The nurse notes that respirations are now 32 breaths/min and stridor and wheezing are audible. What is the priority intervention for this patient? A. Insertion of chest tube B. Insertion of arterial line C. Emergency intubation D. Administration of pain medication

C. Emergency intubation Early intubation is the priority for smoke inhalation injuries, and this patient is displaying airway problems. Pain is important, but airway is of a higher priority. There is no indication for a chest tube. Insertion of an arterial line would be beneficial but is not the top priority.

A patient has sustained a traumatic, full-thickness burn injury to the chest wall. The patient now shows symptoms that include rapid, shallow respirations; poor chest excursion; agitation; and wheezing. Arterial blood gases reveal an increasing partial pressure of carbon dioxide (PaCO2). What action should the nurse anticipate next? A. Administration of albuterol 2.5 mg SVN B. Immediate escharotomy C. Intubation and mechanical ventilation D. Administration of anxiolytic therapy

C. Intubation and mechanical ventilation ACCORDING TO VALE & BOOK ANSWER IS B - Immediate escharotomy Circumferential, full-thickness burns to the chest wall can lead to restriction of chest wall expansion and decreased compliance. Clinical manifestations of chest wall restriction include rapid, shallow respirations; poor chest wall excursion; and severe agitation. Intubation addresses these issues.

Which laboratory value provides information regarding the severity of impaired perfusion and helps determine the adequacy of therapies in the patient with septic shock and multiple-organ dysfunction syndrome (MODS)? A. Serum albumin B. Serum glucose C. Serum lactate D. Serum creatinine

C. Serum lactate Serum lactate levels provide information regarding the severity of impaired perfusion and the presence of lactic acidosis. The values differ significantly in multiple-organ dysfunction syndrome (MODS) survivors and nonsurvivors.

A patient has sustained a burn related to spilling a cup of hot liquid onto the right hand. Symptoms include skin that is bright red and mottled at the affected area with a wet and weeping appearance and diffuse blister formation. The burned area is excruciatingly painful and sensitive to air current. What is the appropriate classification for this burn? A. Deep-dermal partial thickness B. Thermal C. Superficial D. Superficial dermal

C. Superficial dermal A partial-thickness or superficial dermal (second-degree) burn involves the upper third of the dermis. These burns usually are caused by brief contact with flames, hot liquid, or exposure to dilute chemicals. A light to bright red or mottled appearance characterizes superficial second-degree burns. These wounds may appear wet and weeping, may contain bullae, and are extremely painful and sensitive to air currents. Fluid can lift off the thin, damaged epidermis, causing blister formation.

An older patient is admitted with partial-thickness burns on the buttocks, perineum, and both legs after climbing into a bathtub without testing the water first. What type of injury is the patient experiencing? A. Radiation B. Electrical C. Thermal D. Chemical

C. Thermal Thermal burns are caused by steam, scald, heat, and fire. Radiation burns are caused by industrial or medical equipment but appear similar to thermal burns. Electrical burns are caused by alternating or direct current exposure or lightning. Chemical burns are caused by acid or alkaline substances.

A burn patient complains of a pain level of 9 (on a scale of 0 to 10). If all of the following medications are ordered, which medication would be the most appropriate for the nurse to administer? A. 50 mg meperidine IM B. 5 mg diazepam IV C. 2 mg lorazepam PO D. 10 mg morphine IV

D. 10 mg morphine IV IV pain medication should be administered. IM and PO are not predictable routes in burn patients, and the patient wants something for pain, not anxiety (diazepam and lorazepam).

A postoperative patient has a heart rate of 110 beats/min and blood pressure (BP) of 110/80 mm Hg (previously 130/60 mm Hg). Urine output has been 20 mL/h for the past 3 hours, capillary filling time is 5 seconds, the skin is cool, the neck veins are flattened, and the patient is complaining of thirst. The nurse suspects the may be experiencing which disorder? A. Anaphylaxis B. Cardiogenic shock C. Cardiac tamponade D. Hypovolemic shock

D. Hypovolemic shock The patient is experiencing hypovolemic shock as evidenced by decreased urine output, tachycardia, and increased capillary filling time. In cardiac tamponade, heart tones would be muffled and neck veins would be distended. In cardiogenic shock, the blood pressure (BP) would be elevated and the neck veins would be distended. With an allergic reaction, there would be signs of allergic response, such as urticaria, anxiety, and respiratory distress.

Fluid resuscitation is critically important in burn patients to help prevent shock. What fluid is most appropriate for resuscitation in burn patients? A. 5% dextrose in water B. Normal saline C. Half-normal saline D. Lactated Ringer solution

D. Lactated Ringer solution Lactated Ringer solution, an isotonic crystalloid, is the resuscitation fluid used most often. Given in large amounts, it can restore cardiac output to normal in most patients. It is preferred over normal saline because it most closely matches extracellular fluid.