Burn Question's Evolve

According to the Rule of Nines for calculating the percentage of burns, the nurse should assign what percentage to a burn in the genitalia? 1% 4.5% 9% 18%

1% Rationale The Rule of Nines is a formula used for calculating the percentage of burns during initial assessment of a burn patient. The genitals are assigned 1%. Burns in the head and arms are assigned 9% each. Burns on the lower extremities are assigned 18% each. Burns in the chest and back are assigned 18% for each side. pp. 432-433

A patient is admitted with second- and third-degree burns covering the face, entire right upper extremity, and the right anterior trunk area. Using the rule of nines, what should the nurse calculate the extent of these burns as being? 18% 22.5% 27% 36%

22.5% Rationale Using the rule of nines, for these second- and third-degree burns, the face encompasses 4.5% of the body area, the entire right arm encompasses 9% of the body area, and the entire anterior trunk encompasses 18% of the body area. Because the patient has burns on only the right side of the anterior trunk, the nurse would assess that burn as encompassing half of the 18%, or 9%. Therefore adding the three areas together (4.5 + 9 + 9); the nurse would correctly calculate the extent of this patient's burns to cover approximately 22.5% of the total body surface area. Eighteen percent, 27%, and 36% are incorrect calculations. pp. 432-433

A patient is brought to the emergency department after an automobile accident with severe burns over the front lower extremities, abdomen, chest, and both sides of the arms. Using the rule of nines chart, calculate the extent of the burn injuries. Fill in the blank using a whole number.

54% Rationale Refer to Figure 25-4B. The front of each lower extremity would be 18% (9% each); the abdomen/chest area would be 18%; both sides of both arms would be 18% (4.5% for each side of each arm). 18 + 18 + 18 = 54%. pp. 432-433

A nurse is caring for a patient who has sustained burns over the entire surfaces of both arms, the anterior trunk, and the right leg. The nurse uses the rule of nines to estimate the percentage of the burn surface area as what? 27% 36% 54% 72%

54% Rationale The " rule of nines" is a method used to determine the body surface area (BSA) of a burn injury. It assigns 9% to each arm, 9% to the head, 18% to the anterior torso, 18% to the posterior torso, 18% to each leg, and 1% to the genitals. The other answer options are incorrect applications of the rule of nines BSA estimate. pp. 432-433

A nurse is planning care for a patient with a 30% body surface area burn injury. Which statement regarding the nutritional status of this patient is true? Maintaining a hypermetabolic state reduces the patient's risk for infection. Decreased protein intake will decrease the chance of renal complications. Controlling the temperature of the environment reduces caloric requirements. A hypermetabolic state results in poor healing and increased protein and lipid needs.

A hypermetabolic state results in poor healing and increased protein and lipid needs. Rationale A burn injury causes a hypermetabolic state, resulting in protein and lipid catabolism that can inhibit wound healing. Therefore the patient with a burn injury requires increased calories and protein to enable the healing process. Protein intake in the burn patient should be increased to promote wound healing. Renal function is monitored for complications, which is low risk with burns, because the need for protein is increased. A hypermetabolic state is not desired and is a complication of a burn injury. Controlling the temperature of the environment has no effect on caloric requirements. p. 442

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

"After a month, I will be able to go to the beach to get a tan." Rationale Burn patients must protect healed burn areas from direct sunlight for about three months to prevent hyperpigmentation and sunburn injury. They should always wear sunscreen when they are outside. Water-based moisturizers are appropriate for itching. Pressure garments and masks should never be worn over unhealed wounds and, once a wearing schedule has been established, are removed only for short periods while bathing. Pressure garments are worn up to 24 hours a day for as long as 12 to 18 months. The range-of-motion exercises are important to prevent contractures that may develop as new tissue shortens. p. 446

Which statement from a co-worker regarding the fluid and electrolyte shifts that occur during burn injuries requires correction? "Exudate is an example of second spacing." "Accumulation of fluid in the interstitium is second spacing." "Edema and blister formation are examples of third spacing." "Movement of fluid to the areas with no or minimal fluid is third spacing."

"Exudate is an example of second spacing." Rationale Exudate is an example of third spacing. Accumulation of fluid in the interstitium is second spacing. Edema and blister formation are examples of third spacing. Third spacing is the movement of fluid to the areas with no or minimal fluid. p. 434

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

"I should hold regular home fire exit drills." Rationale Regular home fire exit drills ensure the family knows the primary escape routes in case of any flame accidents at home. Frayed wires lack protective insulation, and contact may result in electrical injuries. Gasoline or kerosene should never be used to start a fire. Outdoor activities should be avoided during electrical storms. p. 430

A nurse is teaching a group of parents how to reduce the risk for scalding and inhalation burns. Which statement made by a participant indicates a need for further teaching? "I should set the hot water heater at 120° F." "I should light candles near an open window." "I should use only hard-wired smoke detectors." "I should check the temperature of bath water with the back of my hand."

"I should light candles near an open window." Rationale Candles should not be left unattended or placed in an open window, because this increases the risk for a fire. The water heater should be set at no more than 120° F to reduce the risk for burning. Hard-wired smoke detectors do not require batteries; therefore this increases the safety of the home environment. Water temperature should be checked with the back of the hand or a bath thermometer. p. 430

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

"I will make sure the hot water temperature is set at 140° F (60° C)." Rationale Hot water heaters set at 140° F (60° C) or higher are a burn hazard in the home; the temperature should be set at less than 120° F (40° C). A risk-reduction strategy for household fires is to encourage regular home fire exit drills. Gasoline or other flammable liquids should never be used to start a fire. Installation of smoke and carbon monoxide detectors can prevent inhalation injuries. Hard-wired smoke detectors do not require battery replacement; battery-operated smoke detectors may be used. p. 430

Which statement made by a student nurse regarding clinical manifestations associated with severe burns indicates the need for further education? "The patient's altered mental status is due to hypoxia." "The patient with larger burns may develop paralytic ileus." "The patient with severe burns is most likely to be in shock." "The patient is unconscious and cannot answer until intubated."

"The patient is unconscious and cannot answer until intubated." Rationale The patient with severe burns may have shifting levels of consciousness. However, once the patient is intubated he or she will not be able to answer questions verbally. This statement indicates the need for further education. Altered mental status results from hypoxia. Paralytic ileus occurs in patients with larger burns. The patient with severe burns is in shock. p. 437

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 patient with burns of the feet A patient with an inhalation injury An elderly patient with third-degree burns A patient with burns involving minor joints A patient with partial thickness burns involving 8% of total body surface area

A patient with burns of the feet A patient with an inhalation injury 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. p. 432

A nurse is providing care to a patient with an electrical burn injury. The patient is experiencing premature ventricular contractions (PVCs) and laboratory tests indicate the presence of myoglobinuria. For which complication will the nurse monitor? Pulmonary edema Metabolic asphyxiation Acute tubular necrosis (ATN) Acute respiratory distress syndrome

Acute tubular necrosis (ATN) Rationale Electrical burns often cause dysrhythmias and myoglobinuria. The myoglobin pigments travel to the kidneys and block the renal tubules, resulting in acute tubular necrosis (ATN). Pulmonary edema, metabolic asphyxiation, and acute respiratory distress syndrome are complications associated with smoke and inhalation burn injury. p. 431

A nurse is attending to a patient with extensive burns. What prophylactic treatment should the nurse plan to prevent a Curling's ulcer in this patient? Select all that apply. Antacids Antidiarrheal H 2-histamine blockers Proton pump inhibitors Calcium channel blockers

Antacids H 2-histamine blockers Proton pump inhibitors Rationale Antacids are used prophylactically to neutralize the acids present in the stomach. H 2-histamine blockers (e.g., ranitidine) are used to inhibit histamine, which causes an increase in acid levels. Proton pump inhibitors (e.g., esomeprazole) help to inhibit the secretion of hydrochloric acid, which increases as a 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 a Curling's ulcer. Calcium channel blockers have no effect on protecting the gastrointestinal tract or on preventing development of Curling's ulcers. p. 441

A nurse is attending to a patient with partial-thickness burns on the hands and legs. What actions should the nurse perform as a part of the wound care for the emergent phase of treatment? Select all that apply. Avoid using topical antibiotics. Administer a tetanus antitoxin. Perform debridement as required. Avoid using antimicrobial dressings. Assess the extent and depth of the burns.

Administer a tetanus antitoxin. Perform debridement as required. 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. p. 438

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

Administer 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 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. p. 441

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

Administering 7000 mL 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 the Parkland formula based on body surface area (BSA), 4 mL/kg × BSA; therefore (4 mL × 100 kg) × 35 = 14,000 mL. The Parkland formula calls for half of the total fluids to be given over the first 8 hours, with the remaining given over the next 16 hours. Therefore the IV fluid prescription would be 7000 mL over 8 hours and 7000 mL over the next 16 hours. Administering 3500 mL of colloid IV fluids over the first 8 hours or 140 mL/hr of colloid IV fluids for 24 hours is incorrect because the volumes are incorrect and colloid fluids are not used during the fluid resuscitation period for burns (first 24 hours). p. 439

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

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. pp. 443-444

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

Assess bowel sounds every eight hours. Begin early enteral feeding with smaller-bore tubes. Begin the feedings slowly at a rate of 20 to 40 mL/hr. Rationale The nurse should assess bowel sounds every eight hours to ensure proper functioning of the bowels before starting oral nutrition. The nurse should also begin early enteral feeding with smaller-bore tubes, because this preserves gastrointestinal (GI) function, increases intestinal blood flow, and promotes optimal conditions for wound healing. The feedings should begin slowly at a rate of 20 to 40 mL/hr to protect the GI function and gradually increase as the patient improves. Assessing the respiratory rate every two hours is not related to nutritional therapy. Large amounts of feeding within the first six hours may overload the system and affect the GI function. p. 442

A patient is brought to the emergency department (ED) with partial-thickness burns on the hands and chest caused by a fire at the patient's house. What actions should the nurse perform to provide appropriate burn management for this patient? Select all that apply. Assess for inhalation injury. Provide 100% humidified oxygen. Avoid dry dressings on the wounds. Assess airway, breathing, and circulation. Avoid mechanical ventilation for 24 hours.

Assess for inhalation injury. Provide 100% humidified oxygen. Assess airway, breathing, and circulation. Rationale The patient should be assessed for inhalation injury. Because these burns are caused by a fire, there is a high likelihood that the patient might have inhaled fumes. After assessing the airway, the nurse should provide 100% humidified oxygen to ensure adequate ventilation. The nurse should assess the patency of the airway as well as respirations and plan for the need for intubation accordingly. Dry dressings on the wounds may be applied to cover the wounds, if required. Mechanical ventilation may be required in case of significant inhalation injury. p. 435

A patient is being treated for burns on the face and ears due to a fire at home. What precautions should the nurse take to protect the ears from damage? Select all that apply. Avoid using pillows. Keep ears free from pressure. Apply a heavy gauze dressing for fast healing. Wrap ears with sterile gauze after applying ointment. Elevate patient's head by placing rolled towel under shoulders.

Avoid using pillows. Keep ears free from pressure. Elevate patient's head by placing rolled towel under shoulders. Rationale Ears should be kept free from pressure because of their poor vascularization and tendency to become infected. Avoid using pillows, because the pressure on ear cartilage may cause chondritis, and the ear may adhere to the pillowcase, causing pain and bleeding. The patient's head is elevated by placing a rolled towel under the shoulders to reduce pressure over the ears. It helps to prevent pressure necrosis. A heavy gauze dressing should not be applied, because it can put pressure on the ears and damage them. Ears are not to be wrapped with sterile gauze after applying ointment in order to avoid pressure over the ears. p. 441

Which intervention would the nurse provide when caring for a patient with a burn injury who is in the in the acute phase? Encourage and assist patient with self-care as possible Discuss possible need for home care nursing Discuss possible reconstructive surgery Begin intravenous (IV) fluid replacement

Encourage and assist patient with self-care as possible Rationale Encouraging and assisting the patient with self-care as much as they are able begins in the acute phase. Discussing the need for both home care following discharge and the need for reconstructive surgery occur during the rehabilitation phase. Beginning fluid replacement occurs in the emergent phase. pp. 437-438

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

Begin fluid replacement. Cover burned areas with dry dressings. Establish IV access with two large-bore catheters. Rationale Begin fluid replacement to compensate for fluid loss. Cover the burned areas with dry dressings to begin the healing process and thus prevent contamination. An intravenous access should be established with two large-bore catheters to enable large amounts of fluid replacements. Supplemental oxygen is required to maintain adequate perfusion. The injured limb should be kept elevated above the heart level to prevent and decrease swelling. p. 434

A patient has sustained thermal injuries amounting to approximately 30% of his or her total body surface area. What action should the nurse take first? Cover the burned body area with ice. Immerse the burned body area in cool water. Check for a patent airway, breathing, and circulation. Cover the burned area with a clean, cool, tap water-dampened towel.

Check for a patent airway, breathing, and circulation. Rationale The first step in the management of a person who has sustained thermal injuries 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 total body surface area, 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. p. 433

A patient has thermal burns on the face, including the cheeks and the area around the eyes. Which action would the nurse take? Turn eyelashes inward towards the eyeball. Wrap sterile gauze around the face. Cover the face with ointment and gauze. Apply ointment only without the use of gauze.

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 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. p. 441

The nurse collaborates with the health care team regarding the treatment of partial-thickness second-degree burn to the chest, abdomen, and both anterior thighs sustained by a patient. Which treatment does the nurse recognize as appropriate and within the scope of nursing practice? Application of autografts and daily sterile dressing changes Twice-weekly wound cleaning and sterile dressing changes Daily wound cleaning with debridement and sterile dressing changes Daily wound cleaning with hydrotherapy and clean dressing changes

Daily wound cleaning with debridement and sterile dressing changes Rationale Daily wound cleansing 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. pp. 439-440

A nurse is providing care to a patient with a partial-thickness burn. Which clinical manifestation does the nurse anticipate? Coagulation necrosis Damage to all skin elements Destruction of all nerve endings Damage to epidermis and dermis involving varying depths

Damage to epidermis and dermis involving varying depths Rationale Burns may be superficial or deep thickness. Partial-thickness burns involve damage to the epidermis and dermis at varying depths. Coagulation necrosis, damage to all skin elements, and the destruction of nerve endings are observed in full-thickness burn injuries. p. 432

A patient sustains a second-degree (partial-thickness) burn. Which layer(s) of skin does the nurse inspect for damage? Epidermis only Muscle and bone Epidermis and dermis Epidermis, dermis, and subcutaneous tissue

Epidermis and Dermis Rationale In a second-degree, or partial-thickness, burn, both the epidermis and dermis are damaged. A first-degree superficial burn, such as sunburn, involves only the epidermis. A third- or fourth-degree full-thickness burn may involve muscle and bone. A third-degree deep partial- to full-thickness burn may include the epidermis, dermis, and subcutaneous tissue. p. 432

A nurse is assessing a patient with a burn injury. Which clinical manifestation does the nurse anticipate due to thrombosis in the capillaries of the burned tissue? Elevated heart rate Elevated hematocrit Decreased blood pressure Decreased erythrocyte count

Decreased erythrocyte count Rationale Thrombosis in the capillaries of burned tissue results in a loss of circulating erythrocytes (RBCs). An elevated heart rate and decreased blood pressure are signs of hypovolemic shock, which is caused by a massive shift of fluids out of the blood vessels. Hematocrit is elevated in burn injuries due to the hemoconcentration that results from fluid loss. p. 434

A nurse notes decreased reflexes during the physical assessment of a patient who was admitted with a burn injury. What is the likely cause for this clinical manifestation? Decreased water levels Increased sodium levels Increased albumin levels Decreased potassium levels

Decreased potassium levels Rationale A decreased level of potassium, known as hypokalemia, results from the loss of potassium from the burn wounds. Clinical manifestations include muscle weakness, leg cramps, paresthesias, and decreased reflexes. Decreased levels of water and increased levels of sodium do not affect reflexes in patients with burn injuries. Increased sodium levels result in thirst, a dry and furry tongue, lethargy, and seizures. pp. 434, 436

A patient with a flash burn injury is admitted to the emergency department. The nurse notes a bright red area with blisters that blanches with the application of pressure. The patient also reports severe pain when the burn is exposed to air. Which type of burn is present? Superficial burn Full-thickness burn Deep partial-thickness burn Superficial partial-thickness burn

Deep partial-thickness burn Rationale A bright red area with blisters, blanching upon pressure, and severe pain in the patient indicates a deep partial-thickness burn. Superficial and superficial partial-thickness burns are characterized by erythema, but no blisters, with pain and mild swelling. Full-thickness burns are characterized by dry, waxy, leathery skin that is insensitive to pain due to nerve destruction. p. 437

In caring for a patient with burns to the back, the nurse knows that the patient is moving out of the emergent phase of burn injury when what happens? Serum sodium and potassium increase Serum sodium and potassium decrease Edema and arterial blood gases improve Diuresis occurs and hematocrit decreases

Diuresis occurs and hematocrit decreases Rationale In the emergent phase, the immediate, life-threatening problems from the burn, hypovolemic shock, and edema are treated and resolved. Toward the end of the emergent phase, fluid loss and edema formation end. Interstitial fluid returns to the vascular space and diuresis occurs. Urinary output is the most commonly used parameter to assess the adequacy of fluid resuscitation. The hemolysis of red blood cells (RBCs) and thrombosis of burned capillaries also decreases circulating RBCs. When the fluid balance has been restored, dilution causes the hematocrit levels to drop. Initially sodium moves to the interstitial spaces and remains there until edema formation ceases, so sodium levels increase at the end of the emergent phase as the sodium moves back to the vasculature. Initially potassium level increases as it is released from injured cells and hemolyzed RBCs, so potassium levels decrease at the end of the emergent phase when fluid levels normalize. pp. 434, 436

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? Select all that apply. Do not cover the burned part with ice. Do not remove any burnt cloth from the body. Do not immerse the burned part in cool water. Cool large burns for not more than 10 minutes. Apply ice to the burned part as early as possible.

Do not cover the burned part with ice. Do not immerse the burned part in cool water. 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. Burnt clothes can be removed gently to avoid further tissue damage; however, clothes which are adhered to the body should not be removed. p. 433

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

Dyspnea Wheezing Altered mental status Rationale Dyspnea, wheezing, and an altered mental status are manifestations of a lower airway lung injury associated with burns. Edema and blisters are manifestations of an upper airway lung injury associated with burns. p. 431

A patient with severe electric burns is admitted to the burn unit. When assessing the patient, what symptoms does the nurse know would indicate this patient is hyperkalemic? Select all that apply. Palpitations ECG changes Muscle weakness Decreased reflexes Cardiac dysrhythmias

ECG changes Muscle weakness Cardiac dysrhythmias Rationale Electrical burns cause massive deep muscle injury, which leads to a release of large amounts of potassium into the blood stream. This can lead to hyperkalemia, which can be noted by related ECG changes. Muscle weakness can occur due to increased potassium levels. Cardiac dysrhythmias can be a result of elevated potassium levels. Palpitations and decreased reflexes are seen in hypokalemia. p. 443

The nurse is reviewing the fluid and electrolyte shifts that occur during burn injury. Which of these occur during the emergent stage of a burn injury? Select all that apply. Movement of potassium into the cells. Adherence of albumin to vascular walls. Edema in nonburned areas (third-spacing). Elevated hematocrit caused by hemoconcentration. Movement of water and sodium to the interstitial fluid.

Edema in nonburned areas (third-spacing). Elevated hematocrit caused by hemoconcentration. Movement of water and sodium to the interstitial fluid. Rationale During the emergent phase, sodium and water rapidly shift to the interstitial spaces and remain there until edema formation ceases. The hematocrit is elevated because of hemoconcentration related to fluid loss. Fluid also moves to areas that normally have minimal to no fluid, a phenomenon termed third spacing. Albumin also shifts into the interstitial spaces, contributing to the edema. A potassium shift develops initially because injured cells and hemolyzed red blood cells (RBCs) release potassium into the circulation. pp. 434, 436

A patient with a burn injury is brought to the emergency department. The nurse notes white, leathery skin, dysrhythmias, and a loss of consciousness. Which type of burn injury does the nurse suspect? Thermal Electrical Chemical Inhalational

Electrical Rationale Electrical burns occur from the intense heat of an electrical current. Electrical burns present with dry and leathery skin, dysrhythmia, and a loss of consciousness. Thermal burns occur due to hot liquids or flames, resulting in skin injuries ranging from superficial to full-thickness. Chemical burns cause protein damage and liquefaction. Inhalation injury, which results from breathing hot air or harmful chemicals, causes respiratory tract damage. p. 431

Which burn injury results in tissue anoxia? Thermal burn Chemical burn Electrical injury Smoke and inhalational injury

Electrical injury Rationale Electrical injury causes tissue anoxia due to nerve damage and nerve death. The injury sustained by a thermal burn is dependent on the temperature of the burning agent and the length of exposure. Chemical burns can cause tissue damage and eyes can be injured if a splash occurs. Smoke and inhalation injury result in hypoxia. p. 431

The nurse is planning care for a patient with partial- and full-thickness skin destruction related to burn injury of the lower extremities. Which interventions should the nurse expect to include in this patient's care? Select all that apply. Escharotomy Administration of diuretics Daily cleansing and debridement Application of topical antimicrobial agent Intravenous (IV) and oral pain medications

Escharotomy Daily cleansing and debridement Application of topical antimicrobial agent Intravenous (IV) and oral pain medications Rationale Pain control is essential in the care of a patient with a burn injury. Daily cleansing and debridement, as well as application of an antimicrobial ointment, are expected interventions used to minimize infection and enhance wound healing. An escharotomy (a scalpel incision through full-thickness eschar) frequently is required to restore circulation to compromised extremities. With full-thickness burns, myoglobin and hemoglobin released into the bloodstream can occlude renal tubules. Adequate fluid replacement is used to prevent this occlusion. pp. 439-441

A patient arrives in the burn unit with erythema, pain, and mild swelling following a burn injury while cooking. Based on the wound observation and patient symptoms, the nurse should document the depth of the burn as what? First degree Second degree Third degree Fourth degree

First Degree Rationale Burns which are painful, erythematous, and associated with mild swelling are first-degree burns. Second-degree burns are associated with vesicles and appear shiny. Third- and fourth-degree burns are white, waxy, and are insensitive to pain due to nerve destruction. p. 434

Which type of burn injury occurs on the layers of subcutaneous fat, muscle, or deeper structures? Sunburn Full thickness burn Deep partial thickness burn Superficial partial thickness burn

Full Thickness Burn Rationale A full thickness burn is a burn of the layers of subcutaneous fat, muscle, or deeper structures. A superficial partial thickness burn is a burn of the epidermis layer; a sunburn is a type of superficial partial thickness burn. A deep partial thickness burn involves the dermis layer, between the epidermis and subcutaneous layers. p. 432

A nurse is providing care to a patient who was admitted to the hospital with third-degree burns. Which clinical manifestations should the nurse anticipate? Select all that apply. Erythema Fluid-filled vesicles Hard, leathery skin Insensitivity to pain Mild to moderate edema

Hard, leathery skin Insensitivity to pain Rationale Third-degree burns cause full-thickness skin destruction. Clinical manifestations include hard, leathery skin and insensitivity to pain due to nerve destruction. Erythema is observed in first-degree burns. Second-degree burns are characterized by fluid-filled vesicles and mild to moderate edema. p. 434

To determine the adequacy of fluid resuscitation in patients who have sustained burns, the nurse should assess which measurements of cardiac parameters? Select all that apply. Heart rate less than 120 beats/minute Manual systolic BP greater than 90 mm Hg Arterial line systolic BP greater than 90 mm Hg Manual mean arterial pressure greater than 65 mm Hg Arterial line mean arterial pressure greater than 65 mm Hg

Heart rate less than 120 beats/minute Arterial line systolic BP greater than 90 mm Hg Arterial line mean arterial pressure greater than 65 mm Hg Rationale The cardiac parameters which help to assess adequacy of fluid resuscitation are heart rate less than 120 beats/minute, arterial line systolic blood pressure greater than 90 mm Hg, and arterial line mean arterial pressure greater than 65 mm Hg. Manual blood pressure and manual mean arterial blood pressure are invalid in burns because of edema and vasoconstriction. p. 439

A nurse is triaging a patient who has arrived in the emergency department with burns as a result of a fire. Which patient symptoms indicate an upper airway injury? Select all that apply. Dyspnea Hoarseness Difficulty swallowing Copious secretions Carbonaceous sputum

Hoarseness Difficulty swallowing Copious secretions Rationale An inhalation injury in the upper airways involves the mouth, oropharynx, and/or larynx. It may cause hoarseness in the voice due to the effect on the larynx. There may be difficulty in swallowing due to involvement of the mouth and oropharynx. There may be copious secretion in response to the injury to the airway. The injury to the lower airway involves trachea, bronchioles, and alveoli, and may cause carbonaceous sputum and dyspnea. p. 431

A patient is brought to the emergency department (ED) following an inhalation injury. The patient has sustained burns on the face, neck, and chest due to a fire in the home. Which would help to confirm the diagnosis of upper airway injury? Select all that apply. Dyspnea Wheezing Hoarseness Singed nasal hair Difficulty in swallowing

Hoarseness Singed nasal hair Difficulty in swallowing Rationale Upper airway injury may be caused by thermal burns or the inhalation of hot air, steam, or smoke. Hoarseness occurs due to laryngeal edema. Singed nasal hair is an obvious sign of inhalation of burned particles or smoke. Difficulty in swallowing is present due to edema and blistering of the oropharynx. Dyspnea can be observed where there has been an inhalation injury to the lower airway that is caused by breathing toxic chemicals or smoke that affects the trachea, bronchioles, and alveoli. Wheezing is a symptom found in an inhalation injury affecting the lower airway. p. 435

Which complications occur in a patient with metabolic asphyxiation? Select all that apply. Hypoxia Cardiac standstill Protein hydrolysis Hydrogen cyanide poisoning Acute respiratory distress syndrome

Hypoxia Hydrogen Cyanide Poisoning Rationale Metabolic asphyxiation is a type of smoke and inhalation injury that occurs due to inhalation of carbon monoxide or hydrogen cyanide. In this condition, the oxygen delivery or consumption is impaired, resulting in hypoxia. Hydrogen cyanide poisoning also occurs in metabolic asphyxiation in the absence of burn injury to the skin. Cardiac standstill occurs in an electrical injury. Protein hydrolysis occurs in a chemical injury. Acute respiratory distress syndrome occurs in a lower airway injury. p. 430

Which clinical manifestations are observed in a patient in the emergent phase of a burn injury? Select all that apply. Increased appetite Increased heart rate Increased urine output Decreased respiratory rate Decreased blood pressure

Increased Heart Rate Decreased Blood Pressure Rationale During the emergent phase of a burn injury, the patient exhibits tachycardia and hypotension. Other clinical manifestations during this phase include a loss of appetite, a decreased urine output, and tachypnea. pp. 437-438

A nurse is providing care to a patient admitted to the burn unit. Which pathophysiologic changes does the nurse anticipate in this patient? Select all that apply. Increased viscosity Decreased hematocrit Decreased blood volume Increased vascular permeability Decreased peripheral resistance

Increased Viscosity Decreased blood volume Increased vascular permeability Rationale In a burn injury, the viscosity of body fluids is increased, the blood volume is reduced, and vascular permeability is increased. Hematocrit and peripheral resistance are increased in burn injuries. pp. 434, 436

When assessing a patient suffering from inhalation burns on the face and chest, what findings should a nurse anticipate? Select all that apply. Increasing hoarseness Location of contact points Leathery white charred skin Darkened oral or nasal membranes Productive cough with black sputum

Increasing Hoarseness Darkened oral or nasal membranes Productive cough with black sputum Rationale In inhalation burns, either the respiratory tract is exposed to intense fumes or heat, or the patient inhales noxious chemicals or smoke. Increasing hoarseness is seen due to irritation of the upper airway during inhalation and the laryngeal edema caused by inhalation injury. Some other signs include darkened oral or nasal membranes and productive cough with black sputum, which are evident due to charring of the membranes of the respiratory tract. Location of contact points is done in case of electrical burns. In this case, the skin may appear leathery white and charred. p. 435

A nurse is providing care to a patient who suffered burns to the perineum. For what is the patient at risk of developing? Infection to the respiratory tract Infection from urine contamination Infection to the vascular and nerve supply Infection because of poor blood supply to the cartilage

Infection from urine contamination Rationale The perineum is the part of the body occupied by urogenital passages and the rectum. A patient with burns to the buttocks or perineum is at an increased risk for infection from urine or feces contamination. A patient with burns to the face and neck is susceptible to infection of the respiratory tract. Burns to the hands and feet put the patient at risk for infection of the vascular and nerve supplies. Infection because of poor blood supply to the cartilage is found in patients with ear and nose burns. p. 433

A patient with burns needs permanent skin grafting. Which grafts should the nurse consider? Select all that apply. Integra AlloDerm Autograft Homograft Heterograft

Integra AlloDerm 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 patient's own skin and can be used for permanent grafting. Homograft is obtained from cadaveric skin and can be used as temporary graft from 3 days to 2 weeks. Heterograft is obtained from porcine skin and can be used as temporary graft from three days to two weeks. p. 440

The patient in the emergent phase of a burn injury is being treated for pain. What medication should the nurse anticipate using for this patient? Intravenous (IV) morphine sulfate Subcutaneous (SQ) tetanus toxoid Intramuscular (IM) hydromorphone Oral (PO) oxycodone and acetaminophen

Intravenous (IV) morphine sulfate Rationale IV medications are used for burn injuries in the emergent phase to deliver relief rapidly and prevent unpredictable absorption as would occur with the IM route. Tetanus toxoid may be administered, but not for pain. The PO route is not used because gastrointestinal function is slowed or impaired because of shock or paralytic ileus, although oxycodone and acetaminophen may be used later in the patient's recovery. p. 441

A nurse is attending to a patient with burns. When considering the use of antibiotics, what factors does the nurse consider? Select all that apply. It is essential to check the patient for allergies to sulfa. Systemic antibiotics are routinely used to control burn wound flora. Silver-impregnated dressings can be left in place from 3 to 14 days. Silver sulfadiazine or mafenide acetate creams should never be used. Topical antimicrobial agents may be applied after the wound cleansing.

It is essential to check the patient for allergies to sulfa. Silver-impregnated dressings can be left in place from 3 to 14 days. Topical antimicrobial agents may be applied after the wound cleansing. Rationale The nurse should assess for a sulfa allergy, because some prescribed antibiotics may contain sulfa. Silver-impregnated dressings can be left in place from 3 to 14 days, depending on the patient's clinical situation and the particular product. Topical antimicrobial agents may be applied after the wound cleansing to facilitate healing, and then the affected area should be covered with a light dressing. Systemic antibiotics are not routinely used to control burn wound flora, because the burn eschar has little or no blood supply, and consequently, little antibiotic is delivered to the wound. Also, the routine use of systemic antibiotics increases the chance of developing multidrug-resistant organisms. Silver sulfadiazine and mafenide acetate creams are also used as burn antimicrobial creams. pp. 441-442

When caring for a patient with an electrical burn injury, which prescription from the health care provider should the nurse question? Urine for myoglobin Lactated Ringer's at 25 mL/hr Mannitol 75 gm intravenous (IV) Sodium bicarbonate 24 mEq every 4 four hours

Lactated Ringer's at 25 mL/hr Rationale Electrical injury puts the patient at risk for myoglobinuria, which can lead to acute renal tubular necrosis (ATN). Treatment consists of infusing lactated Ringer's at 2 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 prevention and treatment of ATN. Mannitol also can be used to maintain urine output. The urine would be monitored also for the presence of myoglobin. Sodium bicarbonate may be given to alkalinize the urine. p. 439

A nurse is assessing a patient who was injured using heavy industrial cleanser while working at a factory. For which complications will the nurse monitor? Select all that apply. Hypoxia Liquefaction Tissue anoxia Protein hydrolysis Metabolic acidosis

Liquefaction Protein hydrolysis Rationale A chemical burn results from contact with an alkali, such as an industrial cleanser. When the alkalis come in contact with skin, they adhere to the tissue, resulting in protein hydrolysis and liquefaction. Hypoxia occurs in smoke and inhalation injuries. Tissue anoxia and metabolic acidosis occur in patients with electrical burns. pp. 429-430

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

Lorazepam, an anxiolytic Intravenous fentanyl, a short-acting opioid Rationale Burn patients experience two kinds of pain: (1) continuous, background pain that might be present throughout the day and night; and (2) treatment-induced pain associated with dressing changes, ambulation, and rehabilitation activities. With background pain, a continuous intravenous (IV) infusion of an opioid (e.g., hydromorphone) allows for a steady, therapeutic level of medication. For treatment-induced pain, premedicate with an analgesic and an anxiolytic via the IV or oral route. For patients with an IV infusion, a potent, short-acting analgesic, such as fentanyl, often is effective. If an IV infusion is not present, slow-release, twice-a-day opioid medications (e.g., morphine) are indicated. The morphine would not be appropriate for this patient, because the patient is receiving an IV pain medication infusion. A sleeping pill is not appropriate at this time. p. 441

A patient who escaped from a burning building, which was enclosed with no ventilation, is brought to the emergency department. The patient is confused, has difficulty breathing, and has nasal burns. Which condition does the nurse suspect? Pulmonary edema Lower airway injury Upper airway injury Carbon monoxide poisoning

Lower Airway Injury Rationale A patient who was trapped in an enclosed burning building with no ventilation and is exhibiting confusion, dyspnea, and nasal burns is most likely experiencing a lower airway burn injury. Pulmonary edema may occur but not until 12 to 24 hours after the initial insult. Clinical manifestations of an upper airway injury include blisters, edema, difficulty in swallowing, and total airway obstruction. Carbon monoxide poisoning results in hypoxia, in which oxygen consumption is impaired. p. 431

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

Monitor for signs of complications. Continue assessing oxygenation needs. Continue to monitor respiratory status. Rationale The nurse should monitor for signs of respiratory complications of burns to plan for appropriate respiratory therapy. Continue assessing oxygenation needs to plan for any alternations in oxygen supply. Continue to monitor the respiratory status to ensure proper breathing and circulation. Avoiding supplemental oxygen is not advisable, because oxygen needs may be assessed and started as required. Preparing for discharging the patient needs to be planned in the rehabilitation phase after the patient has recovered. p. 434

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

Morbid Obesity Prolonged immobility Rationale The risk factors for the development of venous thromboembolism a burn patient are morbid obesity and prolonged immobility. These patients may develop stasis of blood due to immobility, which results in development of venous thromboembolism. Young age is not a risk factor for venous thromboembolism; rather, old age predisposes a person to venous thromboembolism. Usually lower-extremity burns are risk factors for venous thromboembolism, because they cause stagnation of blood. First-degree burn of a finger is not an extensive burn and hence not a risk factor for venous thromboembolism. p. 437

Which fluid and electrolyte change occurs during the early emergent phase of burn injury? Increased excretion of urine Increased colloidal osmotic pressure Return of interstitial fluid to the vascular space Movement of sodium and water into interstitial fluids

Movement of Sodium and Water into the interstitial fluids. Rationale After the burn, in the emergent phase, the capillary walls become more permeable, causing the movement of sodium, water, and plasma proteins into the interstitial spaces and surrounding tissues. An increased excretion of urine and the return of interstitial fluid to the vascular spaces occurs toward the end of the emergent phase. During the early emergent phase, colloidal osmotic pressure is decreased with progressive protein loss from the vascular spaces. pp. 434, 436

Which complication is caused by an electric burn? Myoglobinuria Systemic toxicity Protein hydrolysis Metabolic asphyxiation

Myoglobinuria Rationale Electric burns often cause the release of myoglobin from injured muscle tissues into circulation, causing myoglobinuria. Systemic toxicity and protein hydrolysis results from chemical injury. Smoke and inhalation injury results in metabolic asphyxiation. p. 431

An unconscious patient who suffered an electrical burn is admitted to the emergency department. For which complications will the nurse monitor? Select all that apply. Myoglobinuria Systemic toxicity Pulmonary edema Cervical spine injury Severe metabolic acidosis

Myoglobinuria Cervical spine injury Severe metabolic acidosis Rationale Patients with an electrical injury are at risk from myoglobinuria, cervical spine injury, and severe metabolic acidosis. Myoglobinuria occurs because myoglobin from the injured tissue is released into circulation, causing muscle and blood vessel damage. Contact with electrical currents causes muscle contractions, which can fracture the vertebrae and bones. Electrical injury carries the risk of severe metabolic acidosis. Systemic toxicity occurs in patients with chemical burns. Pulmonary edema occurs due to smoke and inhalation injuries. p. 431

The ambulance reports that it is transporting a patient to the emergency department who has experienced a full-thickness thermal burn from a grill. What manifestations should the nurse expect? Severe pain, blisters, and blanching with pressure Pain, minimal edema, and blanching with pressure Redness, evidence of inhalation injury, and charred skin No pain, waxy white skin, and no blanching with pressure

No pain, waxy white skin, and no blanching with pressure Rationale With full-thickness burns, the nerves and vasculature in the dermis are destroyed so there is no pain; the tissue is dry and waxy looking or may be charred, and there is no blanching with pressure. Severe pain, blisters, and blanching occur with partial-thickness (deep, second-degree) burns. Pain, minimal edema, blanching, and redness occur with partial-thickness (superficial, first-degree) burns. p. 434

The nurse recalls which description as the most accurate regarding a deep partial-thickness burn? Painful with weeping blisters Minimal damage to the epidermis Charring visible in the deepest areas Necrotic tissue through all layers of the skin

Painful with weeping blisters Rationale A deep partial-thickness burn involves the epidermal and dermal layers of the skin. It is characterized by a wet, shiny, weeping surface marked by blisters and is painful and very sensitive to the touch. Necrosis and charring are seen with a full-thickness burn. Redness and pain with minimal damage to the epidermis are characteristics of a superficial, or first-degree, burn. p. 432

A nurse is providing care to a patient with burn injuries. Laboratory tests indicate the patient is experiencing hypernatremia. For which clinical manifestations should the nurse monitor? Select all that apply. Seizures Paresthesia Tachycardia Muscle cramps Dried, furry tongue

Seizures Dried, Furry Tongue Rationale Hypernatremia is an excess amount of sodium in the body, which is seen after successful fluid resuscitation required in the treatment of a significant burn injury. The manifestations of hypernatremia include seizures and a dried, furry tongue. Paresthesia is one of the symptoms of hypokalemia. Tachycardia and muscle cramps are observed in hyponatremia. p. 442

The emergency department nurse is caring for a patient whose skin is discolored and edematous, and the patient is exhibiting decreased muscle coordination. Which complication is the patient at risk of developing? Paralysis Cardiac fibrillation Acute tubular necrosis Acute respiratory distress

Paralysis Rationale Discoloration of skin, edema, and decreased muscle coordination indicate chemical burns. Chemical burns occur due to contact with acids, alkalis, or organic compounds. Chemicals that remain in contact with the skin for a long time reach the nerve supply, which can result in paralysis. Cardiac fibrillation and acute tubular necrosis may occur in patients with electrical injury. Acute respiratory distress may be observed in patients with smoke or inhalation injury to the lower airways. p. 436

While planning physical therapy for a patient suffering from burns, which should be included? Select all that apply. Perform exercises before wound cleansing. Practice physical therapy only occasionally. Perform passive and active ROM on all joints. Provide pillows to sleep for patients with neck burns. Perform exercises during and after wound cleansing.

Perform passive and active ROM on all joints. Perform exercises during and after wound cleansing. Rationale Perform passive and active 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 hyperextension and avoid contractures. p. 446

A patient is brought to the emergency department (ED) with a history of inhalation burn injury. The patient has also sustained burns on the face, neck, and hands. Which actions would the nurse perform immediately? Select all that apply. Wait for laboratory reports. Observe for the next two hours. Provide 100% humidified oxygen. Observe for signs of respiratory distress. Check for evidence of inhalation of smoke.

Provide 100% humidified oxygen. Observe for signs of respiratory distress. 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 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. p. 435

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

Provide enteral tube feeding, starting at 20 mL/hour. Rationale Nonintubated patients with a burn of less than 20% total body surface area (TBSA) will generally be able to eat enough to meet their nutritional needs. Intubated patients and those with larger burns require additional support. Enteral feedings (gastric or intestinal) have almost entirely replaced parenteral feeding. Early enteral feeding, usually with smaller-bore tubes, preserves gastrointestinal (GI) function, increases intestinal blood flow, and promotes optimal conditions for wound healing. In general, begin the feedings slowly at a rate of 20 to 40 mL/hr and increase to the goal rate within 24 to 48 hours. p. 442

When teaching the patient about the use of range-of-motion (ROM), what explanations should the nurse give to the patient? Select all that apply. The exercises are the only way to prevent contractures ROM will show the patient that movement still is possible Active and passive ROM maintain function of body parts Movement facilitates mobilization of leaked exudates back into the vascular bed Active and passive ROM can be done only while the dressings are being changed

ROM will show the patient that movement still is possible Active and passive ROM maintain function of body parts Movement facilitates mobilization of leaked exudates back into the vascular bed Rationale Active and passive ROM maintain function of body parts and reassure the patient that movement still is possible are the explanations that should be used. Contractures are prevented with ROM as well as splints. Movement facilitates mobilization of fluid in interstitial fluid back into the vascular bed. Although it is good to collaborate with physical therapy to perform ROM during dressing changes because the patient already has taken analgesics, ROM can and should be done throughout the day. p. 441

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

Reddening of the Skin Rationale The clinical appearance of superficial partial-thickness burns includes erythema, blanching with pressure, and pain and minimal swelling with no vesicles or blistering during the first 24 hours. p. 432

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

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. pp. 447-448

A patient presents in the emergency department with a bright red burned area, with moist, red, shiny vesicles and blister formation. The patient reports severe pain when the site is exposed to air. Which type of burn will the nurse document in the patient's medical record? First-degree burn Third-degree burn Fourth-degree burn Second-degree burn

Second-degree burn Rationale A second-degree burn manifests as a bright red burned area with moist, red, shiny vesicles and blister formation. There is also severe pain upon exposure to air. In first-degree burns, there is erythema, blanching on application of pressure, and no vesicles or blisters. Third- and fourth-degree burns are characterized by dry, waxy, leathery skin that is insensitive to pain. p. 432

A patient who sustained burns in a house fire develops a paralytic ileus. What does the nurse suspect to be the cause of this complication? Sepsis Enteral feedings Opioid analgesics Increased gastric acid secretion

Sepsis Rationale Paralytic ileus is caused when the burn patient experiences sepsis. Enteral feedings may cause the patient to experience diarrhea. Constipation is a side effect for opioid analgesics, which are required for pain management. Curling's ulcer occurs as a result of increased gastric acid secretion. p. 443

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

Severe Pain Red, shiny vesicles Mild to moderate edema Rationale Clinical manifestations of second-degree burns include severe pain, the appearance of fluid-filled vesicles, the appearance of "shiny" skin, and mild to moderate edema. Blanching is observed in first-degree burns, and white, waxy skin is seen in third- and fourth-degree burns. p. 434

A patient is admitted to the burn unit with second-degree thermal burns. Which characteristics of a second-degree thermal burn should the nurse expect to find during the physical assessment? Select all that apply. Severe pain Mild edema Fluid-filled vesicles Waxy, white, hard skin Visible thrombosed vessels

Severe pain Mild edema Fluid-filled vesicles Rationale Second-degree burns show epidermal and dermal involvement to varying depths. These burn injuries are characterized by fluid-filled vesicles that are erythematous, glossy, and damp. The patient may complain of severe pain caused by nerve injury. Mild to moderate edema may be present. Waxy, white, hard skin and visible thrombosed vessels are found in third-degree burns. p. 432

A patient is admitted to the emergency department with first- and second-degree burns after being involved in a house fire. Which assessment findings would alert the nurse to the presence of an inhalation injury? Select all that apply. Singed nasal hair Increasing hoarseness Painful swallowing Burns on the upper extremities History of being trapped in an enclosed space

Singed nasal hair Increasing hoarseness Painful swallowing History of being trapped in an enclosed space Rationale Reliable clues to the occurrence of inhalation injury include the presence of facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral and nasal membranes, carbonaceous sputum, history of being trapped in an enclosed space, altered mental status, and "cherry red" skin color. Burns on the upper extremities do not signify an inhalation injury. p. 435

The nurse is assessing a patient admitted to the emergency department after the inhalation of toxic chemicals. Which finding indicates a lower airway injury? Blisters Singed nasal hairs Total airway obstruction Substernal retractions

Singed nasal hairs Rationale Singed nasal or facial hair is one of the manifestations of a lower airway injury, involving the trachea, bronchioles, and alveoli. Blisters, total airway obstruction, and substernal retractions can be seen in patients suffering from an upper airway burn injury. p. 431

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

Suggest a high-protein diet. Suggest a high-carbohydrate diet. 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. A low-calorie food may not meet the calorie requirements of the patient and leads to malnutrition and delayed wound healing. An adequate intake of fluids is essential for healing. p. 446

A nurse is assessing a patient who was burned after contact with gasoline. For which complication does the nurse monitor? Liquefaction Systemic toxicity Protein hydrolysis Severe metabolic acidosis

Systemic toxicity Rationale Gasoline is an organic compound that causes chemical burns. This compound produces systemic toxicity in patients. Liquefaction and protein hydrolysis occur due to chemical burns resulting from alkalis. Electrical injury results in severe metabolic acidosis. pp. 429-430

Following fluid resuscitation, which parameter indicates a stable condition? Urine output 0.5 mL/kg/hr Heart rate more than 120 beats/minute Systolic blood pressure (BP) more than 90 mm Hg Mean arterial pressure (MAP) less than 65 mm Hg

Systolic blood pressure (BP) more than 90 mm Hg Rationale Hourly assessments of the adequacy of fluid resuscitation are best made using clinical parameters. Urine and cardiac parameters are most commonly used. Urine output should be 0.5 to 1 mL/kg/hr and 75 to 100 mL/hr for an electrical burn patient with evidence of hemoglobinuria or myoglobinuria. The MAP should be greater than 65 mm Hg, systolic BP greater than 90 mm Hg, and heart rate less than 120 beats/minute. MAP and BP are best measured by an arterial line. p. 439

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

Tachycardia Rationale Albuterol stimulates beta 2 receptors in the lungs to cause bronchodilation. However, it is a non-cardioselective agent so it also stimulates the beta 2 receptors in the heart to increase the heart rate. Restlessness and GI upset may occur, but will decrease with use. Hypokalemia does not occur with albuterol. p. 439

A patient arrives at the burn unit with large burns on the chest and abdomen. While assessing the patient, the nurse suspects full-thickness burns. What findings are likely to be found in the patient with full-thickness burns? Select all that apply. The patient is shivering. The burned areas have blisters. The burned areas are very painful. The patient has low blood pressure. The patient has absence of bowel sounds.

The patient is shivering The patient has low blood pressure The patient has absence of bowel sounds Rationale The patient with severe burns is likely to be in shock from hypovolemia and may have low blood pressure. The patient experiences shivering as a result of chilling that is caused either by heat loss, anxiety, or pain. The patient with a larger burn area may develop a paralytic ileus, which may be accompanied with absent or decreased bowel sounds. The burned areas have blisters filled with fluid and protein in cases of partial-thickness burns. Superficial to moderate partial-thickness burns are very painful. p. 437

A patient who sustained burn injuries is receiving daily treatments. The patient tells the caregiver, "The nurses enjoy hurting me." What should the nurse suspect? Choose the best answer. This patient must be having hallucinations. This patient might be having schizophrenia. This patient has a serious psychiatric condition. This is a normal reaction to an extraordinary life event.

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 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. p. 447

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

To decrease pain To prevent blistering 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. pp. 446-447

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

To prevent blood clots Rationale A patient with severe burns is at greater risk of venous thromboembolism. Omega-3 fatty acids are natural anticoagulants that decrease platelet aggregation. Eating foods rich in tryptophan, not omega-3 fatty acids, improves the patient's sleeping pattern. Tryptophan is an amino acid that blocks body wakeup cycles and promotes sleep. Foods rich in protein and fats, like peanut butter and red meat, help the patient gain weight. Avoiding spicy foods and drinking plenty of pure water helps decrease stomach acid. pp. 441-442

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

To promote sleep To reduce anxiety 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. p. 441

Why does the nurse apply enzymatic debriding agents to a patient with severe wounds? To decrease blood loss To remove the old microbial agent To protect the reepithelializing keratinocytes To remove dead tissue from the healthy wound bed

To remove dead tissue from the healthy wound bed Rationale Enzymatic debriding agents are made of natural products like collagen. Enzymatic debriding agents speed up the removal of dead tissue from the healthy wound bed. Skin grafting, a part of wound care, promotes massive blood loss in patients. To prevent this, topical application of epinephrine is advised. Washing the patient's wound with normal saline-moistened gauze removes the old antimicrobial agent. Paraffin gauze dressing protects the re-epithelializing keratinocytes from damage. This dressing resurfaces and closes the open bed wound. pp. 443-444

A patient is brought to the emergency department (ED) with severe burns on the legs and feet. Which factors lead the nurse to believe the patient may have full-thickness burns? Select all that apply. Touch sensation is impaired. Blanching with pressure is observed. Lack of blanching with pressure is observed. Wounds appear mottled white, pink to cherry-red. Wounds appear waxy white, dark brown, or charred.

Touch sensation is impaired. Lack of blanching with pressure is observed. Wounds appear waxy white, dark brown, or charred. Rationale Touch sensation is impaired due to impaired nerve endings in full-thickness burns. Lack of blanching with pressure is observed, because all skin elements are destroyed. Wounds appear waxy white, dark brown, or charred in full-thickness burns, because all skin elements and local nerve endings are destroyed, and coagulation necrosis is present. Blanching with pressure is observed in partial-thickness burns, because varying degrees of both the epidermis and dermis are involved, and skin elements of regeneration are viable. Wounds appear mottled white, pink to cherry-red in a partial-thickness burn. p. 434

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

Use antibiotic ointments. Instill methylcellulose eye drops. Arrange for ophthalmology examination. Rationale Eye care for corneal burns or edema includes antibiotic ointments. An ophthalmology examination should be conducted on all patients who have sustained facial burns. The use of methylcellulose drops or artificial tears is recommended for moisture and additional comfort. Waiting for laboratory reports does not help the patient; rather, the nurse can start the basic examination and treatment in the process mentioned above. Avoid giving any misleading information, such as telling the patient that periorbital edema is serious. This can frighten the patient and prevent eye opening. The nurse should assure the patient that the swelling is not permanent. p. 441

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

Use sterile gloves when applying ointments and sterile dressings. Wear nonsterile, disposable gloves when washing the dirty wound. 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. pp. 439-440

While assessing a patient with severe burns, the nurse suspects hypokalemia. What possible causes should the nurse evaluate? Select all that apply. Vomiting Renal failure Adrenal insufficiency IV therapy without potassium Prolonged gastrointestinal (GI) suction

Vomiting IV therapy without potassium Prolonged gastrointestinal (GI) suction Rationale Hypokalemia occurs due to lack of potassium. Excessive vomiting causes loss of body fluids leading to a loss of potassium. Prolonged GI suction also causes fluid loss and decreases potassium levels. The IV therapy without potassium fails to compensate for the loss of potassium, and the deficiency persists thus resulting in hypokalemia. Renal failure and adrenal insufficiency are the causes of hyperkalemia, which is marked by an increase in potassium levels. p. 443

A patient presents with scalding burns on the chest and abdomen. On examination, the nurse suspects that the patient has superficial partial-thickness burns. What findings would the nurse expect to find? Select all that apply. Wounds are red and painful. Wounds are dry and leathery. Wounds are moist and blistered. There is blanching with pressure. The burned area has minimal edema.

Wounds are red and painful. There is blanching with pressure. The burned area has minimal edema. Rationale In cases of superficial partial-thickness burns, wounds appear red and painful. This is due to the superficial epidermal damage causing hyperemia. The tactile and pain sensation remains unaffected. There is blanching with pressure due to superficial epidermal damage. The burned area has minimal edema because only the superficial layers are involved. In cases of full-thickness burns, the wounds become dry and leathery, and all the skin elements are destroyed. Wounds are moist and blistered in deep partial-thickness burns. This is because varying depths of epidermis and dermis are involved, and it causes formation of fluid-filled vesicles. These have a wet appearance if the vesicles rupture. p. 432

A patient is admitted to the burns ward with deep partial-thickness burns on the hands. What characteristics is the nurse likely to find when performing an examination of the wound? Select all that apply. Wounds are painless. Wounds are wet and shiny. Wounds are painful to touch. Wounds appear pink to cherry-red. Wounds appear black and leathery.

Wounds are wet and shiny. Wounds are painful to touch. Wounds appear pink to cherry-red. Rationale Partial-thickness wounds are wet and shiny due to serous exudates. These wounds are painful to touch due to nerve injury. Wounds appear pink to cherry-red. Wounds are painless in full-thickness burns due to nerve destruction. Wounds appear black and leathery in full-thickness burns, because all skin elements and local nerve endings are destroyed, and coagulation necrosis is present. p. 439

When instructing a patient's caregiver about caring for a person with burns of more than 10% of total body surface area (TBSA), what does the nurse advise? Select all that apply. Wrap the patient in a blanket. Gently remove burned clothing. Leave adherent clothing in place. Apply ice all over the burned area. Leave the affected area open to air.

Wrap the patient in a blanket. Gently remove burned clothing. Leave adherent clothing in place. Rationale In case of severe burns, the patient should be wrapped in a blanket to avoid further contamination and to provide warmth. Burned clothing should be gently removed to prevent further tissue damage. Adherent clothing should be left in place until the patient is transferred to the hospital to avoid tissue damage. Leaving the affected area open to air can cause more contaminations and is not advisable. Applying ice all over the burned area can cause hypothermia and is not advisable. p. 433

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

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