Burn Management
Which precautions would the nurse take when performing wound care on a burn patient? SELECT ALL THAT APPLY a. The nurse wears personal protective equipment. b. The nurse wears the same gown and masks for all patients. c. The nurse uses nonsterile gloves when applying ointments. d. The nurse uses sterile gloves when applying sterile dressings e. The nurse uses nonsterile gloves when removing contaminated dressings.
a. The nurse wears personal protective equipment. d. The nurse uses sterile gloves when applying sterile dressings e. The nurse uses nonsterile gloves when removing contaminated dressings. Rationale The nurse wears PPE, such as a disposable gown, mask, and gloves, to prevent the spread of infection. The nurse uses sterile gloves when applying sterile dressings to prevent infections. The nurse uses nonsterile gloves when removing contaminated dressings for self-protection. The nurse should not wear the same gown and masks for all patients to avoid cross-contamination. It is necessary to wear new equipment before treating a new patient. The nurse should not necessarily use nonsterile gloves when applying ointments. Because the wound is open, sterile gloves should be used to prevent contamination.
While caring for a patient with burns, a nurse wraps the patient's wound with tubular elastic gauze. Which are the reasons behind this action? Select all that apply. a. To decrease pain b. To prevent blistering c. To decrease itchiness d. To reduce venous return e. To enhance local immunity
a. To decrease pain b. To prevent blistering c. To decrease itchiness Rationale The interim pressure due to tubular elastic gauze decreases pain and itchiness, and prevents blistering. It promotes venous return rather than reducing it. It does not enhance local immunity.
A patient with partial-thickness burns is being treated with zolpidem, and the family inquires why the patient is receiving the medication. Which responses by the nurse are appropriate? Select all that apply. a. "It is used to help promote sleep." b. "It is used to reduce anxiety." c. "It is used to promote wound healing." d. "It is used to prevent thromboembolism." e. "It is used to provide short-term amnesic effects."
a. "It is used to help promote sleep." b. "It is used to reduce anxiety." e. "It is used to provide short-term amnesic effects." Rationale Zolpidem is a sedative-hypnotic medicine and is given to patients suffering from burns. Zolpidem promotes sleep, reduces anxiety, and provides short-term amnesic effects. Nutritional support is used to promote wound healing. Anticoagulants are used to prevent thromboembolism.
A nurse works in an emergency department. Which patients are appropriate for the nurse to refer to the burn care unit? Select all that apply. a. A patient with an inhalation injury b. A patient with burns of the feet c. A patient with burns involving minor joints d. An elderly patient with third-degree burns e. A patient with partial thickness burns involving 8% of total body surface area
a. A patient with an inhalation injury b. A patient with burns of the feet d. An elderly patient with third-degree burns Rationale A burn care unit provides advanced care to burn patients to prevent complications and keep the condition from worsening. Inhalation injury increases the risk of airway obstruction and requires a referral to the burn unit. Burns of both feet is associated with complications like contractures, and needs to be referred to the burn care unit. Third-degree burns in any age-group require referral. Burns involving minor joints do not require referral to burn centers; however, burns of major joints require referral. Partial thickness burns require referral if they involve more than 10% of the body surface area.
Which nursing interventions are appropriate for providing enteral feeding to a patient who is intubated and has burns of more than 5% of the total body surface area (TBSA)? Select all that apply a. Check gastric residuals frequently. b. Asses bowel sounds every eight hours c. Determine whether the nasogastric tube is in place d. Begin the feedings slowly at the rate of 10-20mL/hr. e. Increase the feedings to the goal rate within 24-48 hours.
a. Check gastric residuals frequently. b. Asses bowel sounds every eight hours c. Determine whether the nasogastric tube is in place e. Increase the feedings to the goal rate within 24-48 hours. Rationale A patient that is intubated and has suffered burns to more than 5% of the body surface area may need gastric feedings to meet adequate nutritional requirements. Early enteral feeding helps to preserve gastrointestinal function, increase intestinal blood flow, and promote optimal conditions for wound healing. The nurse should check the placement of the nasogastric tube and assess bowel sounds every 8 hours. The enteral feedings should be started at 20-40 mL/hr and slowly increased to the goal rate within 24-48 hours. Gastric residuals should be checked to rule out delayed gastric emptying.
A nurse is instructing a patient about the immediate steps that need to be taken in the case of electrical burns. What precautions should the nurse instruct as necessary to perform? a. Do not cover the burned part with ice. b. Do not remove any burned clothing from the body. c. Do not immerse the burned part in cool water. d. Cool large burns for not more than 10 minutes. e. Apply ice to the burned part as early as possible.
a. Do not cover the burned part with ice. c. Do not immerse the burned part in cool water. d. Cool large burns for not more than 10 minutes. Rationale The burned body part of a person suffering from an electrical injury should not be covered with ice because it can cause hypothermia and vasoconstriction and can significantly reduce the blood flow to the affected area. Do not immerse the burned part in cold water because it may cause extensive heat loss. Cooling burns for more than 10 minutes can cause hypothermia. Applying ice to the burned part can cause hypothermia. Burned clothes can be removed gently to avoid further tissue damage; however, clothes that are adhered to the body should not be removed.
Which cardiac parameters would the nurse assess to determine the adequacy of fluid resuscitation in a patient who has sustained burns? Select all that apply. a. Heart rate less than 120 beats/minute b. Manual systolic BP greater than 90 mmHg c. Arterial line systolic BP greater than 90 mmHg d. Manual mean arterial pressure greater than 65 mmHg e. Arterial line mean arterial pressure greater than 65 mmHg
a. Heart rate less than 120 beats/minute c. Arterial line systolic BP greater than 90 mmHg e. Arterial line mean arterial pressure greater than 65 mmHg Rationale The cardiac parameters that help to assess the adequacy of fluid resuscitation are heart rate less than 120 beats/minute, arterial line systolic BP greater than 90 mmHg, and arterial line mean arterial pressure greater than 65 mmHg. Manual BP and manual mean arterial BP are invalid in burns because of edema and vasoconstriction.
The nurse is teaching a community group about immediate actions to be taken in the case of burns to more than 10% of body surface area. Which reason would the nurse provide for avoiding the use of ice on the burned body part? Select all that apply. a. Ice can cause hypothermia. b. Ice can cause vasoconstriction. c. Ice can stop further tissue damage. d. Ice can reduce blood flow to the burned area. e. Ice can increase the blood flow to the burned area.
a. Ice can cause hypothermia. b. Ice can cause vasoconstriction. d. Ice can reduce blood flow to the burned area. Rationale Ice can cause hypothermia, resulting in excessive cooling of the burned part and reduction of blood flow to that area. Ice can also cause vasoconstriction, thus causing the blood vessels supplying the burned area to narrow and supply less blood and oxygen. Applying ice does not prevent further tissue damage; instead, it decreases the blood supply, causing delayed wound healing. Ice does not increase the blood flow to the burned area; rather it decreases the blood flow due to vasoconstriction.
A patient which burns needs permanent skin grafting. Which types of grafts would the nurse expect to be considered? Select all that apply. a. Integra b. AlloDerm c. Autograft d. Homograft e. Heterograft
a. Integra b. AlloDerm c. Autograft Rationale Integra is obtained from bovine collagen and glycosaminoglycan bonded to silicone and gives permanent coverage. AlloDerm is obtained from a cellular dermal matrix derived from donated human skin and can be used for permanent grafting. Autograft is from the patient's own skin and can be used for permanent grafting. Homograft is obtained from cadaveric skin and can be used as a temporary graft from three days to two weeks. Heterograft is obtained from porcine skin and can be used as a temporary graft from three days to two weeks. Angela's Note* Heterograft is a Xenograft; Homograft is an Allograft
When planning for burn management, which patients would the nurse refer to a burn center? Select all that apply. a. Patients with hydrochloric acid burns. b. Patients of all ages with first-degree burns. c. Patients of all ages with third-degree burns. d. Patients with 25% deep partial-thickness burns e. Patients with 5% superficial partial-thickness burns.
a. Patients with hydrochloric acid burns. c. Patients of all ages with third-degree burns. d. Patients with 25% deep partial-thickness burns Rationale Patients suffering from hydrochloric acid burns, also known as chemical burns, should be referred to a burn center. Patients of all ages with third-degree burns are severe in condition and should be treated in a burn center. Patients of all ages with partial-thickness burns of more than 10% of body surface area should be referred to a burn center because they are severe types of burns and need specialized treatment, care, and isolation. Patients of all ages with firs-degree burns can be managed in the hospital and assessed. Patients with 5% superficial partial-thickness burns need not necessarily be referred and can be managed in the hospital.
Which intervention would the nurse provide when caring for a patient with a burn injury during the acute phase? a. Provide teaching about the physical aspects of recovery. b. Discuss the possible need for home care nursing. c. Discuss the need for reconstructive surgery. d. Begin IV fluid replacement.
a. Provide teaching about the physical aspects of recovery. Rationale Nurses should provide ongoing support, counseling, and teaching to the patient and the caregiver regarding the physical and emotional aspects of care and recovery. Discussing the need for both home care following discharge and the need for reconstructive surgery occurs during the rehabilitation phase. Beginning fluid replacement occurs in the emergent phase.
A nurse is attending to a patient with extensive burns. Which prophylactic treatment would the nurse plan to prevent Curling's ulcer in this patient. Select all that apply. a. antacids b. Antidiarrheal c. H2-histamine blockers d. Proton pump inhibitors e. Calcium channel blockers
a. antacids c. H2-histamine blockers d. Proton pump inhibitors Rationale Antacids are used prophylactically to neutralize the acids in the stomach. H2-histamine blockers (e.g. ranitidine) are used to inhibit histamine, which causes an increase in acid levels. PPIs (e.g. esomeprazole) help to inhibit the secretion of hydrochloric acid, which increases as stress response to the decreased blood flow to the gastrointestinal tract after burns. Antidiarrheals are useful in providing symptomatic relief for diarrhea. They cannot prevent Curling's ulcer. Calcium channel blockers have no effect on protecting the gastrointestinal tract or on prevent the development of Curling's ulcer.
The nurse recognizes which fluid as recommended for the first 24 hours after a burn? a. 1 to 2 mL lactated Ringer's/kg/percent total body surface area (%TBSA) burned. b. 2 to 4 mL lactated Ringer's/kg/percent total body surface area (%TBSA) burned. c. 6 to 8 mL lactated Ringer's/kg/percent total body surface area (%TBSA) burned. d. 8 to 10 mL lactated Ringer's/kg/percent total body surface area (%TBSA) burned
b. 2 to 4 mL lactated Ringer's/kg/percent total body surface area (%TBSA) burned. Rationale Fluid resuscitation is an important intervention in burn management. It helps to replenish the fluid loss caused by burns and maintain the fluid and electrolyte balance. The fluid recommendation for the first 24 hours is 2 to 4 b. 2 to 4 mL lactated Ringer's/kg/percent total body surface area (%TBSA) burned. A fluid volume of 1 to 2 b. 2 to 4 mL lactated Ringer's/kg/percent total body surface area (%TBSA) burned would be inadequate to meet the patient's requirement. Volumes of 6 to 8 b. 2 to 4 mL lactated Ringer's/kg/percent total body surface area (%TBSA) burned and 8 to 10 b. 2 to 4 mL lactated Ringer's/kg/percent total body surface area (%TBSA) burned may cause fluid overload.
Which actions would the nurse perform as part of wound care during the emergent phase of treatment for a patient with partial-thickness burn on the hands and legs? Select all that apply. a. Avoid using topical antibiotics. b. Administer a tetanus antitoxin. c. Perform debridement as required. d. Avoid using antimicrobial dressings e. Assess the extent and depth of the burns
b. Administer a tetanus antitoxin. c. Perform debridement as required. e. Assess the extent and depth of the burns Rationale The burn management involves emergent phase, acute phase, and rehabilitation phase. The emergent phase involves early management of the burns patient and includes airway management, and fluid and wound therapy. Tetanus antitoxin should be administered to prevent sepsis. Assessment of extent and depth of burns should be done to determine the severity of burns, plan burns management, and consider referring to a burn center. Debridement should be performed as required to keep the wound clean, remove any chemical causing the burn, or to prevent further tissue damage. Use of topical antibiotics and antimicrobial dressings are not of prime importance in the emergent phase; they are usually used in the acute and rehabilitation phases.
A patient's partial-thickness burn injuries were debrided and covered with a silver-impregnated dressing a week ago. Today the nurse notes the wounds have been fully debrided. Which would be the nurse's priority intervention for wound care at this time? a. Reapply a new dressing without disturbing the wound bed. b. Apply fine-meshed petroleum gauze to the debrided areas. c. Wash the wound aggressively with sterile saline three times a day. d. Apply cool compresses for pain relief in between dressing changes.
b. Apply fine-meshed petroleum gauze to the debrided areas. Rationale When the partial-thickness burn wounds have been fully debrided, a protective, coarse- or fine-meshed, greasy-based (paraffin or petroleum) gauze dressing is applied to protect the re-epithelializing keratinocytes as they resurface and close the open wound bed. The nurse would not wash the wound aggressively with saline three times daily, apply cool compresses, or apply a new dressing at this time.
Which patient signs and symptoms noted during triage would indicate to the nurse an upper airway injury? Select all that apply. a. Dyspnea b. Hoarseness c. Difficulty swallowing d. Copious secretions e. Carbonaceous sputum
b. Hoarseness c. Difficulty swallowing d. Copious secretions Rationale An inhalation injury in the upper airway involves the mouth, oropharynx, and/or larynx. It may cause hoarseness in the voice because of the effect on the larynx. There may be difficulty in swallowing because of the involvement of the mouth and oropharynx. There may be copious secretions in response to the injury to the airway. The injury to the lower airway involves the trachea, bronchioles, and alveoli and may cause carbonaceous sputum and dyspnea.
When caring for a patient with an electrical burn injury, which prescription from the health care provider would the nurse question? a. Urine for myoglobin b. Lactated Ringer's at 25mL/hr c. Mannitol 75 gm IV d. Sodium bicarbonate 24 mEq every 4 hours
b. Lactated Ringer's at 25mL/hr Rationale Electrical injury puts the patient at risk for myoglobinuria, which can lead to acute tubular necrosis (ATN). Treatment consists of infusing lactated Ringer's as 2 to 4 mL/kg/% total body surface area (TBSA), a rate sufficient to maintain urinary output at 75 to 100 mL/hr. An infusion rate of 25 mL/hr is not sufficient to maintain adequate urine output in the prevention and treatment of ATN. Mannitol also can be used to maintain urine output. The urine would also be monitored for the presence of myoglobin. Sodium bicarbonate may be given to alkalinize the urine.
Which types of food and drinks would the nurse provide to the patient who is recovering from a full-thickness burn and is in a hypermetabolic state? Select all that apply. a. Tea b. Milkshakes c. Protein powder d. Low-protein food e. High-caloric food
b. Milkshakes c. Protein powder e. High-caloric food Rationale A patient with burns needs a high-calorie diet to compensate for the energy loss and increased protein intake to avoid malnutrition and delayed healing.. Milkshakes have a lot of calories. Protein powder provides high protein. High-caloric food contains calories in large quantities and will help the patient's recovery. Tea does not provide adequate quantities of calories and proteins. Low-protein food is not advised for a patient with burns because the demand for protein is high to promote healing and a faster recovery.
A Nurse is caring for a patient with second- and third-degree burns to 50% of the body. The nurse prepares fluid resuscitation based on knowledge of the Parkland (Baxter) formula that includes which recommendation? a. The total 24-hour fluid requirements should be administered in the first eight hours. b. One half of the total 24-hour fluid requirement should be administered in the first eight hours. c. One third of the total 24-hour fluid requirement should be administered in the first four hours. e. One half of the total 24-hour fluid requirement should be administered in the first four hours.
b. One half of the total 24-hour fluid requirement should be administered in the first eight hours. Rationale Fluid resuscitation with the Parkland (Baxter) formula recommends that one half of the total fluid requirement should be administered in the first eight hours, one quarter of the total fluid requirement should be administered in the second eight hours, and one quarter of the total fluid requirement should be administered in the third eight hours.
When teaching the patient about the use of range of motion (ROM), which explanations would the nurse give to the patient? Select all that apply a. The exercises are the only way to prevent contractures. b. ROM will show that the patient movement still is possible. c. Active and passive ROM maintain function of the body parts. d. Movement facilitates mobilization of leaked exudates back into the vascular bed. e. Active and passive ROM can be done only while the dressings are being changed.
b. ROM will show that the patient movement still is possible. c. Active and passive ROM maintain function of the body parts. d. Movement facilitates mobilization of leaked exudates back into the vascular bed. Rationale The explanations that should be used are that active and passive ROM maintain the function of the body parts and reassure the patient that movement is still possible. Contractures are prevented with ROM as well as splints. Movement facilitates mobilization of fluid in the interstitial fluid back into the vascular bed. Although is is good to collaborate with physical therapy to perform ROM during dressing changes because the patient has already taken analgesics, ROM can and should be done throughout the day.
A patient with partial-thickness burns is now allowed oral feedings. Which nursing interventions would the nurse perform to maintain the patient's nutrition? SELECT ALL THAT APPLY a. Suggest low-calorie foods. b. Suggest a high-protein diet. c. Suggest reduced fluid intake. d. Suggest a high-carbohydrate diet. e. Ask caregivers to get the patient's favorite food.
b. Suggest a high-protein diet. d. Suggest a high-carbohydrate diet. e. Ask caregivers to get the patient's favorite food. Rationale The patient may have a reduced appetite and may not like the food from the hospital. Therefore the caregivers can get the patient's favorite food. A swallowing assessment should be done by a speech pathologist before beginning with oral feeds. The patient should be provided with a high-protein diet to promote tissue healing and avoid malnutrition. A high-carbohydrate diet should be provided to meet the high metabolic demands. Low-calorie foods may not meet the calorie requirements of the patient and may lead to malnutrition and delayed wound healing. An adequate intake of fluids is essential for healing.
Which precautions would the nurse take when changing a burn dressing? Select all that apply. a. Use sterile gloves when removing a contaminated dressing. b. Use sterile gloves when applying ointments and sterile dressings. c. Wear nonsterile, disposable gloves when washing the dirty wound. d. Keep the room cool to decrease the burning sensation of the wound. e. Always wear personal protective equipment, such as masks, gowns, and gloves.
b. Use sterile gloves when applying ointments and sterile dressings. c. Wear nonsterile, disposable gloves when washing the dirty wound. e. Always wear personal protective equipment, such as masks, gowns, and gloves. Rationale The nurse should use sterile gloves when applying ointment and sterile dressings. Nonsterile, disposable gloves should be worn when removing contaminated dressings and washing a dirty wound. The nurse should always wear personal protective equipment before the burn wounds are exposed. The room should be kept warm to prevent shivering in the patient.
Which action is most appropriate for the nurse to take during the early course of care of a patient who has sustained burns covering 35% of the body surface area and weighs 100 kg? a. Administering 3500 of colloid IV fluids over the 8 hours after injury. b. Administering 140mL/hr of colloid IV fluids for the 24 hours after injury. c. Administering 7000mL of crystalloid IV fluids over the 8 hours after injury. d. Administering 14,000 mL of crystalloid IV fluids over the 12 hours after injury.
c. Administering 7000mL of crystalloid IV fluids over the 8 hours after injury. Rationale Crystalloid solutions, such as Ringer's lactate, are indicated for use in the initial IV fluid therapy for a burn patient. IV fluids for the first 24 hours may be calculated with the use of Parkland formula based on body surface area (BSA), 4mLxkgxBSA; therefore (4 mLx100)x35=14,000mL. The Parkland formula calls for half of the total fluids to be given over the first 8 hours and 7000mL over the next 16 hours. Administering 3500mL of colloid IV fluids over the first 8 hours or 140mL/hr of colloid IV fluids for 24 hours is incorrect because the volumes are incorrect and because colloid fluids are not used during the fluid resuscitation period for burns (first 24 hours).
A patient has sustained thermal injuries amounting to approximately 30% of the total body surface area (TBSA). Which action would the nurse take first? a. Cover the burned body area with ice. b. Immerse the burned body area in cool water. c. Check for a patient airway, breathing, and circulation. d. Cover the burned area with a clean, cool, tap water-dampened towel.
c. Check for a patient airway, breathing, and circulation. Rationale The first step in the management of a person who has sustained thermal injures on 10% or more of his or her body surface is to assess the airway, breathing, and circulation. If the injury is less than 10% of the TBSA, then it would be appropriate to cover the burned area with a clean, cool, damp towel, but only after the airway, breathing, and circulation have been checked. It is not appropriate to cover the patient's afflicted area with ice because this can cause hypothermia and vasoconstriction, which would further reduce the blood flow to the injury site. Immersing the patient or the patient's afflicted area in cool water may cause extensive heat loss.
The patient is undergoing treatment for partial-thickness burn on the legs. In which order would the nurse perform the given actions as a part of wound care? a. Debride the loose necrotic tissue. b. Protect the skin graft with dressing. c. Cleanse wounds with soap and water. d. Apply paraffin-based fine-meshed gauze dressing
c. Cleanse wounds with soap and water. a. Debride the loose necrotic tissue. d. Apply paraffin-based fine-meshed gauze dressing b. Protect the skin graft with dressing. Rationale The nurse should first cleanse the wounds with soap and water or normal saline-moistened gauze. This is done to gently remove the old antimicrobial agent and any loosed necrotic tissue, scabs, or dried blood. Next, debridement should be carried out to gently remove loose necrotic tissue and make the wound ready for treatment. When partial-thickness burn wounds are fully debrided, a protective, coarse- or fine-meshed, greasy-based (paraffin or petroleum) gauze dressing is applied. This helps to protect the re-epithelializing keratinocytes as they resurface and close the open wound be. If grafting is necessary, protect the skin graft with the same greasy gauze dressings next to the graft. This layer of dressing should be followed by a saline-moistened layer and dry gauze outer dressings.
A patient has thermal burns on the face, including the cheeks and the area around the eyes. a. Turn eyelashes inward toward the eyeball. b. Wrap sterile gauze around the face. c. Cover the face with ointment and gauze. d. Apply ointment only without the use of gauze.
c. Cover the face with ointment and gauze. Rationale The face is highly vascular and may become edematous after a thermal burn. It should be covered with ointment and gauze to prevent vascularization and swelling. The nurse should ensure that the eyelashes are not turned inward. Wrapping gauze around the face will create pressure on delicate facial structures. The gauze is required to cover the face after the application of ointment to prevent infection.
Which treatment would the nurse recognize as appropriate and within the scope of nursing practice when caring for a patient with partial-thickness second-degree burns to the chest, abdomen, and both anterior thighs? a. Application of autografts and daily sterile dressing changes. b. Twice-weekly wound cleaning and sterile dressing changes c. Daily wound cleaning with debridement and sterile dressing changes. d. Daily wound cleaning with hydrotherapy and clean dressing changes.
c. Daily wound cleaning with debridement and sterile dressing changes. Rationale Daily wound cleaning with debridement and sterile dressing changes is appropriate care for a major burn wound. As a means of promoting healing and preventing infection, wound care and dressing changes are performed once or twice a day with a sterile procedure. The other answer options are not within the scope of nursing practice and may not be appropriate treatment for the burn injury sustained.
When teaching patients and caregivers about the strategies to reduce burn injuries, what essential instructions does the nurse give? Select all that apply. a. Store chemicals in the lowest shelves to avoid mixing up with other household chemicals. b. Perform outdoor activities during lightning storms. c. Ensure an electrical power source is shut off before beginning repairs. d. Never leave burning candles unattended or near windows or curtains. e. Check temperature of bath water with the back of hand or bath thermometer.
c. Ensure an electrical power source is shut off before beginning repairs. d. Never leave burning candles unattended or near windows or curtains. e. Check temperature of bath water with the back of hand or bath thermometer. Rationale Ensure that the electrical power source is shut off before beginning any repairs to avoid electrical burn injury. Never leave candles unattended or near open windows or curtains to avoid fire. Check the temperature of the bath water using the back of the hand or use the bath thermometer to avoid scalding burns, which commonly occur due to hot bathing water. Chemicals should be stored safely, preferably out of reach of children, in clearly written labels. Performing outdoor activities during lightning storms increases the risk of electrical injury from the ongoing lightning.
Which actions would the nurse perform when caring for a patient who received burns from hydrochloric acid on the hands and face? Select all that apply. a. Apply ice to the burned area. b. Never wash the burn with water. c. Flush affected area with lots of water. d. Remove all chemical particles on the skin. e. Remove all clothing containing the chemical.
c. Flush affected area with lots of water. d. Remove all chemical particles on the skin. e. Remove all clothing containing the chemical. Rationale Remove all chemical particles on skin to remove the burn-causing agent from the patient's body. Remove all clothing containing the chemical, because the burning process continues while the chemical is in contact with the skin. Flush affected area with copious amounts of water to irrigate the skin from 20 minutes to two hours after chemical exposure to clear off the chemical on or around the affected area. Applying ice to the burned area does not help to wash away the chemical. Washing the burnt area with water helps to clean off the chemical.
The nurse is teaching strategies to reduce burn injuries to a group of new parents. which parent comment indicates a need for further teaching? a. "we will have fire exit drills once a month at home." b. I will not use gasoline in the fireplace when starting a fire." c. I will make sure the hot water temperature is set at 140 degrees F (60 degrees C)." d. We will install hard-wired smoke detectors on each level of our home.
c. I will make sure the hot water temperature is set at 140 degrees F (60 degrees C)." Rationale Hot water heaters set at 140 degrees F or higher are a burn hazard in the home; the temperature should be set at less than 120 degrees F. A risk-reduction strategy for household fires is to encourage regular home fire exit drills. Gasoline or other flammable liquids should never be used to start a fire. Installation of smoke and carbon monoxide detectors can prevent inhalation injuries. Hard-wired smoke detectors do not require battery replacement; battery-operated smoke detectors may be used.
Which advice would the nurse give the family of an elderly patient to help prevent accidental burns? a. Cook for the patient. b. Stop the patient from smoking. c. Install tap water anti-scald devices. d. Be sure the patient uses an open space heater.
c. Install tap water anti-scald devices. Rationale Installing tap water anti-scald devices will help prevent accidental scald burns that more easily occur in older people because their skin becomes drier and the dermis thinner. Cooking for the patient may be needed at times of illness or in the future, but there is no indication that the patient needs assistance. Stopping the patient from smoking may be helpful to prevent burns but may not be possible. Using an open space heater would increase the patient's risk of being burned and would not be encouraged.
While planning physical therapy for a patient suffering from burns, which intervention would the nurse include in the plan of care? Select all that apply. a. Perform exercises before wound cleansing. b. Practice physical therapy only occasionally. c. Perform passive and active range of motion (ROM) on all joints. d. Provide pillows to sleep for patients with neck burns. e. Perform exercises during and after wound cleansing.
c. Perform passive and active range of motion (ROM) on all joints. e. Perform exercises during and after wound cleansing. Rationale Perform passive and active range of motion (ROM) on all joints to avoid contractures and prevent compromising the patient's cardiopulmonary status. It is not a good habit to practice physical therapy only occasionally. This is because continuous physical therapy throughout burn recovery is imperative if the patient needs to regain and maintain muscle strength and optimal joint function. A good time for exercise is during and after wound cleansing, when the skin is softer and bulky dressings are removed. Performing exercises before wound cleansing is not appropriate. Patients with neck burns should continue to sleep without pillows or with the head hanging slightly over the top of the mattress to encourage hyperflexion and avoid contractures.
A patient is brought to the emergency department (ED) with a suspected inhalation injury and burns on the face, the neck, and the hands. Which actions would the nurse perform immediately? Select all that apply. a. Wait for laboratory reports. b. Observe for the next two hours. c. Provide 100% humidification oxygen. d. Observe for signs of respiratory distress. e. Check for evidence of inhalation of smoke.
c. Provide 100% humidification oxygen. d. Observe for signs of respiratory distress. e. Check for evidence of inhalation of smoke. Rationale Monitoring for signs of smoke or toxic chemical inhalation is an important step to evaluate burn victims. Also assessing for signs of respiratory distress, including increased agitation, anxiety, restlessness, or a change in the rate or character of breathing, is important. Early treatment includes the provision of 100% humidified oxygen and anticipating endotracheal intubation. Observing the patient for the next two hours does not help because treatment must begin at the earliest possible moment. In general, the patient suffering from burns on the face and neck may have mechanical obstruction caused by massive swelling of the tissues and requires intubation within one to two hours after the injury.
The patient received a cultured epithelial autograft (CEA) to the entire left leg. What should the nurse include in the discharge teaching for this patient? a. Sit or lie in a position of comfort b. Wear a pressure garment for eight hours each day c. Refer the patient to a counselor for psychosocial support d. Use the sun to increase the skin color on the healed areas
c. Refer the patient to a counselor for psychosocial support Rationale In the rehabilitation phase, the patient will work toward resuming a functional role in society, but frequently there are body image concerns and grieving for the loss of the way the body looked and functioned before the burn, so continued counseling helps the patient in this phase as well. Putting the leg in the position of comfort is more likely to lead to contractures than to help the patient. If a pressure garment is prescribed, it is used for 24 hours per day for as long as 12 to 18 months. Sunlight should be avoided to prevent injury and sunscreen should always be worn when the patient is outside.
A burn patient has not received any active tetanus immunization within the previous 12 years. Which is the primary nursing measure to help prevent the development of tetanus in the patient? a. Administer tetanus toxoid. b. Provide musculoskeletal relaxants. c. Provide 100% oxygen to the patient. d. Administer the tetanus immunoglobulin.
d. Administer the tetanus immunoglobulin. Rationale Because the patient has not received any active immunization in the past 12 years, tetanus immunoglobulin administration is the primary measure. It would help in preventing the development of tetanus. Tetanus toxoid administration would have been the primary measure if the patient had received active immunization within the past 10 years, Providing 100% oxygen does not ensure aerobic conditions at the burn area. Musculoskeletal relaxants will be helpful only after the patient develops tetanus.
Which types of foods would the nurse encourage for a patient who has sustained a chemical burn on 15% of the total body surface area (TBSA)? a. High fat and high carbohydrate b. Low protein and low carbohydrate c. High protein and low carbohydrate d. High protein and high carbohydrate
d. High protein and high carbohydrate Rationale The patient with a chemical burn of 15% TBSA should be encouraged to eat a high-protein, high carbohydrate diet. Foods high in protein and high in carbohydrates are important for tissue regeneration and promote wound healing. The daily estimated caloric needs should be calculated and regularly reassessed according to the patient's changing condition.
The nurse is caring for a patient with partial- and full-thickness burns to 65% of the body. When planning nutritional interventions for this patient, what dietary choices should the nurse implement? a. Full liquids only b. Whatever the patient requests c. High-protein and low-sodium foods d. High-calorie and high-protein foods
d. High-calorie and high-protein foods Rationale A hypermetabolic state occurs proportional to the size of the burn area. Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. Caloric needs are often in the 5000-kcal range. Failure to supply adequate calories and protein leads to malnutrition and delayed healing.
A patient who sustained burn injuries is receiving daily wound treatments and tells the caregiver, "The nurses enjoy hurting me." Which would the nurse suspect? a. This patient must be having hallucinations. b. The patient might be having schizophrenia. c. This patient has a serious psychiatric condition. d. This is a normal reaction to an extraordinary life event.
d. This is a normal reaction to an extraordinary life event. Rationale Patients who have sustained burn injuries may experience a variety of emotions, including fear, anxiety, anger, guilt, and depression. The given example shows that the patient is angry and depressed, and it is important to reassure that the patient and caregivers that these reactions may be normal and can be expected. The nurse should not assume from this reaction that the patient is experiencing hallucinations or any serious psychiatric conditions, including schizophrenia.
