Burns

Thrombocytopenia 150,000 less than 50%, timing 5-10 days, thrombotic event

3 Ts in HIT

superficial, superficial partial thickness, deep partial thickness, full thickness

4 types of burns

c

A 23-year-old male client who has had a full-thickness burn is being discharged from the hospital. Which information is most important for the nurse to provide prior to discharge? A. How to maintain home smoke detectors B. Joining a community reintegration program C. Learning to perform dressing changes D. Options available for scar removal

d

A 40-year-old male client who was burned was admitted under your care. Assessment reveals he has crackles, respiratory rate of 40/min, and is coughing up blood-tinged sputum. What action will the nurse take first? A. Administer digoxin B. Perform chest physiotherapy C. Monitor urine output D. Place the client in an upright position

b

A burn patient in the rehabilitation phase of injury is increasingly anxious and unable to sleep. The nurse should consult with the provider to further assess the patient for: a. acute delirium. b. posttraumatic stress disorder. c. suicidal intentions. d. bipolar disorder.

a

A client who is admitted after a thermal burn injury has the following vital signs: blood pressure, 70/40; heart rate, 140 beats/min; respiratory rate, 25/min. He is pale in color and it is difficult to find pedal pulses. Which action will the nurse take first? A. Begin intravenous fluids. B. Check the pulses with a Doppler device. C. Obtain a complete blood count (CBC). D. Obtain an electrocardiogram (ECG).

4

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? 1 Elevated heart rate 2 Elevated hematocrit 3 Decreased blood pressure 4 Decreased erythrocyte coun

1,3,5

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. 1 Begin fluid replacement. 2 Avoid supplemental oxygen. 3 Cover burned areas with dry dressings. 4 Lower the burned limbs below heart level. 5 Establish IV access with two large-bore catheters

1,3,4

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. 1 Use antibiotic ointments. 2 Wait for laboratory reports. 3 Instill methylcellulose eye drops. 4 Arrange for ophthalmology examination. 5 Inform the patient that periorbital edema is serious

b

A nurse is caring for a patient who has burns of the ears, head, neck, and right arm and hand. The nurse should place the patient in which position? a. Place the right arm and hand flexed in a position of comfort. b. Elevate the right arm and hand on pillows and extend the fingers. c. Assist the patient to a supine position with a small pillow under the head. d. Position the patient in a side-lying position with rolled towel under the neck.

2

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? 1 The total 24-hour fluid requirement should be administered in the first 8 hours. 2 One-half of the total 24-hour fluid requirement should be administered in the first 8 hours. 3 One-third of the total 24-hour fluid requirement should be administered in the first 4 hours. 4 One-half of the total 24-hour fluid requirement should be administered in the first 4 hours.

2,4,1,3

A nurse is learning about the events involved in burn shock following exposure to burns. Arrange the process in its correct sequential order. 1.Decreased blood volume 2. Increased vascular permeability 3. Increased peripheral resistance 4.Development of edema

4

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? 1 Maintaining a hypermetabolic state reduces the patient's risk for infection. 2 Decreased protein intake will decrease the chance of renal complications. 3 Controlling the temperature of the environment reduces caloric requirements. 4 A hypermetabolic state results in poor healing and increased protein and lipid needs.

1,3,4

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. 1 Increased viscosity 2 Decreased hematocrit 3 Decreased blood volume 4 Increased vascular permeability 5 Decreased peripheral resistance

2,4,5

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. 1 Blanching 2 Severe pain 3 White, waxy skin 4 Red, shiny vesicles 5 Mild to moderate edema

2

A nurse is providing care to a patient who suffered burns to the perineum. For what is the patient at risk of developing? 1 Infection to the respiratory tract 2 Infection from urine contamination 3 Infection to the vascular and nerve supply 4 Infection because of poor blood supply to the cartilage

3,4

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. 1 Erythema 2 Fluid-filled vesicles 3 Hard, leathery skin 4 Insensitivity to pain 5 Mild to moderate edema

4

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? 1 Decreased water levels 2 Increased sodium levels 3 Increased albumin levels 4 Decreased potassium levels

2,3

A nurse working in a burn unit identifies that which patients are at an increased risk of developing venous thromboembolism? Select all that apply. 1 Young age 2 Morbid obesity 3 Prolonged immobility 4 Upper-extremity burns 5 First-degree burn of a finger

B

A patient admitted with severe burns to his face and hands is showing signs of extreme agitation. The nurse should explore the mechanism of burn injury possibly related to: a. excessive alcohol use. b. methamphetamine use. c. posttraumatic stress disorder. d. subacute delirium

1

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? 1 First degree 2 Second degree 3 Third degree 4 Fourth degree

a

A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first? a. Auscultate the patient's lung sounds. b. Determine the extent and depth of the burns. c. Give the prescribed hydromorphone (Dilaudid). d. Infuse the prescribed lactated Ringer's solution.

c

A patient has just arrived in the emergency department after an electrical burn from exposure to a high-voltage current. What is the priority nursing assessment? a. Oral temperature c. Extremity movement b. Peripheral pulses d. Pupil reaction to light

b

A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain adequate nutrition, the nurse should plan to take which action? a. Administer vitamins and minerals intravenously. b. Insert a feeding tube and initiate enteral feedings. c. Infuse total parenteral nutrition via a central catheter. d. Encourage an oral intake of at least 5000 kcal per day.

3

A patient has thermal burns on the face, including the cheeks and the area around the eyes. Which action would the nurse take? 1 Turn eyelashes inward towards the eyeball. 2 Wrap sterile gauze around the face. 3 Cover the face with ointment and gauze. 4 Apply ointment only without the use of gauze

4

A patient is admitted to the burn center with burns of the face, upper chest, and hands after fireworks exploded in the patient's garage, catching the patient's shirt on fire. On assessment, the nurse notes that the patient is coughing up black sputum, has singed nasal hair, darkened oral and nasal membranes, and smoky breath with increasing shortness of breath and hoarseness. Which of these actions would be the most appropriate for the nurse to take next? 1 Insert a Foley catheter and monitor output. 2 Obtain vital signs and a stat arterial blood gas (ABG). 3 Obtain a sputum specimen and send it to the lab stat. 4 Anticipate the need for endotracheal intubation and notify the health care provider.

1,2,3,5

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. 1 Singed nasal hair 2 Increasing hoarseness 3 Painful swallowing 4 Burns on the upper extremities 5 History of being trapped in an enclosed space

c

A patient is brought to the ER with partial thickness burns to his face, neck, arms, and chest. What is the priority? a. Restrict fluids b. Give oral pain medication c. Assess for airway patency d. Apply dressings to the facial burns

3,2,1,4

A patient is suspected to have a smoke inhalation burn and carboxyhemoglobinemia. In what order should the nurse perform the treatment interventions? 1. Check for the patient's pulse. 2. Check for the adequacy of ventilation. 3. Check for a patent airway and soot around nares and tongue. 4. Elevate any burned limbs above the heart to decrease pain and swelling.

3

A patient sustains a second-degree (partial-thickness) burn. Which layer(s) of skin does the nurse inspect for damage? 1 Epidermis only 2 Muscle and bone 3 Epidermis and dermis 4 Epidermis, dermis, and subcutaneous tissue

d

A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital. Which action should the nurse take first? a. Stay at the bedside and reassure the patient. b. Administer the ordered morphine sulfate IV. c. Assess orientation and level of consciousness. d. Use pulse oximetry to check oxygen saturation.

1

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? 1 Sepsis 2 Enteral feedings 3 Opioid analgesics 4 Increased gastric acid secretion

d

A patient who was found unconscious in a burning house is brought to the emergency department by ambulance. The nurse notes that the patient's skin color is bright red. Which action should the nurse take first? a. Insert two large-bore IV lines. b. Check the patient's orientation. c. Assess for singed nasal hair and dark oral mucous membranes. d. Place the patient on 100% O2using a nonrebreather mask.

c

A patient with a 60% burn in the acute phase of treatment develops a tense abdomen, decreasing urine output, hypercapnia, and hypoxemia. Based on this assessment, the nurse anticipates interventions to evaluate and treat the patient for: a. acute kidney injury. b. acute respiratory distress syndrome. c. intraabdominal hypertension. d. disseminated intravascular coagulation disorder.

1

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? 1 Tachycardia 2 Hypokalemia 3 Restlessness 4 Gastrointestinal (GI) distress

c

A patient with burns covering 40% total body surface area (TBSA) is in the acute phase of burn treatment. Which snack would be best for the nurse to offer to this patient? a. Bananas c. Vanilla milkshake b. Orange gelatin d. Whole grain bagel

b

A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take first? a. Monitor the pulses every hour. b. Notify the health care provider. c. Elevate both legs above heart level with pillows. d. Encourage the patient to flex and extend the toes.

b

A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first? a. Assess pain level. c. Check potassium level. b. Place on heart monitor. d. Assess oral temperature.

inhalation

A patient with facial and chest burns is at risk for __________ injury and assessment of airway and breathing is the priority.

2,4,5

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. 1 Suggest low-calorie food. 2 Suggest a high-protein diet. 3 Suggest reduced fluid intake. 4 Suggest a high-carbohydrate diet. 5 Ask caregivers to get the patient's favorite food.

1,3,5

A patient with severe inhalation burns has been receiving treatment for 24 hours. When assessing the patient, what findings would indicate respiratory distress? Select all that apply. 1 Restlessness 2 Increased sleep 3 Increased agitation 4 Increased water intake 5 Increased rate of breathing

b

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

c

A young adult patient who is in the rehabilitation phase after having deep partial-thickness face and neck burns has a nursing diagnosis of disturbed body image. Which statement by the patient best indicates that the problem is resolving? a. "I'm glad the scars are only temporary." b. "I will avoid using a pillow, so my neck will be OK." c. "Do you think dark beige makeup will cover this scar?" d. "I don't think my boyfriend will want to look at me now."

b

A(An) ____________________ often produces a superficial cutaneous injury but may cause cardiopulmonary arrest and transient but severe central nervous system deficits. a. chemical burn b. electrical burn c. heat burn d. infection

acute

Acute delirium is more likely to occur during the _______ phase of injury

lower airway injury

Acute respiratory distress syndrome occurs in a

hypoxia

Agitation in a patient who may have suffered inhalation injury might indicate ____________, and this should be assessed by the nurse first.

cervical spine injury

All patients with electrical burns should be considered at risk for _____________, and assessment of extremity movement will provide baseline data.

a,b,d

An autograft is used to optimally treat a partial- or full-thickness wound that: (Select all that apply.) a. involves a joint. b. involves the face, hands, or feet. c. is infected. d. requires more than 2 weeks for healing.

b

An elderly individual from an assisted living facility presents with severe scald burns to the buttocks and back of the thighs. The caregiver from the ALF accompanies the patient to the emergency department and states that the bath water was too hot and that the patient sat in the water too long. What should the nurse do? a. Ask the caregiver at what temperature the water heater is set in the home. b. Ask the caregiver to step out while examining the patients burn injury. c. Immediately contact the police to report the suspected elder abuse. d. Ask the caregiver to describe exactly how the injury occurred.

a

An employee spills industrial acids on both arms and legs at work. What action should the occupational health nurse take first? a. Remove nonadherent clothing and wristwatch. b. Apply an alkaline solution to the affected area. c. Place a cool compress on the area of exposure. d. Cover the affected area with dry, sterile dressings.

1,4,5

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. 1 Myoglobinuria 2 Systemic toxicity 3 Pulmonary edema 4 Cervical spine injury 5 Severe metabolic acidosis

metabolic asphyxiation

Carbon monoxide (CO) poisoning CO is produced by the incomplete combustion of burning materials *Inhaled CO displaces oxygen* -Hypoxia -Carboxyhemoglobinemia -Death

second

Deep Partial thickness is also known as what degree

d

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

upper

Edema and blisters are manifestations of _______________ airway injury associated with burns.

b

Eight hours after a thermal burn covering 50% of a patient's total body surface area (TBSA), the nurse assesses the patient. The patient weighs 92 kg (202.4 lb). Which information would be a priority to communicate to the health care provider? a. Blood pressure is 95/48 per arterial line. b. Urine output of 41 mL over past 2 hours. c. Serous exudate is leaking from the burns. d. Heart monitor shows sinus tachycardia of 108.

c

Esomeprazole (Nexium) is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which nursing assessment would best evaluate the effectiveness of the drug? a. Bowel sounds c. Stool occult blood b. Stool frequency d. Abdominal distention

Hypokalemia S/S

Fatigue, Anorexia, N/V, Muscle weakness, Decreased GI motility, Dysrhythmias, Paresthesia, Flat T waves on ECG

2

Fluid resuscitation is an important intervention in burn patients. The nurse recognizes that what fluid is recommended for the first 24 hours after a burn? 1 1 to 2 mL lactated Ringer's/kg/%TBSA burned 2 2 to 4 mL lactated Ringer's/kg/%TBSA burned 3 6 to 8 mL lactated Ringer's/kg/%TBSA burned 4 8 to 10 mL lactated Ringer's/kg/%TBSA burned

3

Following fluid resuscitation, which parameter indicates a stable condition? 1 Urine output 0.5 mL/kg/hr 2 Heart rate more than 120 beats/minute 3 Systolic blood pressure (BP) more than 90 mm Hg 4 Mean arterial pressure (MAP) less than 65 mm Hg

1,5

For which clinical manifestations should the nurse monitor a burn-injured client with hypernatremia after successful fluid resuscitation? Select all that apply. 1 Seizures 2 Confusion 3 Tachycardia 4 Dizziness 5 Hypertension

a

How will the nurse position a client with a burn wound to the posterior neck to prevent contractures? A. Have the client turn the head from side to side. B. Keep the client in a supine position without the use of pillows. C. Keep the client in a semi-Fowler's position with her or his arms elevated. D. Place a towel roll under the client's neck or shoulder.

Octreotide

IV med given to decrease blood flow to portal system or to the liver

4

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? 1 Serum sodium and potassium increase 2 Serum sodium and potassium decrease 3 Edema and arterial blood gases improve 4 Diuresis occurs and hematocrit decrease

early intubation

In inhalation injury, the airway may become edematous quickly, making intubation difficult. __________________ is recommended to protect the airway.

C

In patients with extensive burns, edema occurs in both burned and unburned areas because of: a. catecholamine-induced vasoconstriction. b. decreased glomerular filtration. c. increased capillary permeability. d. loss of integument barrier.

insulin

Nondiabetic patients may require ____________ because stress and high calorie intake may lead to temporary hyperglycemia.

deep partial thickness burn

Normally heal spontaneously, clinical appearance is more blistering, severe pain, mild to moderate edema, red pink shiny most skin

c

On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which of the following prescribed actions should be the nurse's priority? a. Monitoring urine output every 4 hours. b. Continuing to monitor the laboratory results. c. Increasing the rate of the ordered IV solution. d. Typing and crossmatching for a blood transfusion.

b

Patients with burns may have mesh grafts or sheet grafts. Which of the following sites is most likely to have a sheet graft applied? a. Arm b. Face c. Leg d. Chest

lower airway injury

Pulmonary edema may develop 12-48 hours after initial exposure may see ARDS (NONCARDIAC pulmonary edema) s/s hoarseness, presence of facial burns, singed nasal hair, dark thick sputum, darkened oral and nasal membranes, wheezing, altered mental status

Hyperkalemia

Renal failure is a cause of ______________

b

Silver is used as an ingredient in many burn dressings because it: a. stimulates tissue granulation. b. is effective against a wide spectrum of wound pathogens. c. provides topical pain relief. d. stimulates wound healing.

first

Superficial Partial Thickness burn is also known as what degree

2 large bore IVs

TBSA greater than 15

central line

TBSA greater than 30

4

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? 1 Severe pain, blisters, and blanching with pressure 2 Pain, minimal edema, and blanching with pressure 3 Redness, evidence of inhalation injury, and charred skin 4 No pain, waxy white skin, and no blanching with pressure

a

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

d,a,b,c

The correct priority order of actions in prehospital primary survey for burn injuries is: _______________, _______________, _______________, _______________. (Put a comma and space between each answer choice.) a. Assess ABCs and cervical spine. b. Provide oxygen therapy if smoke inhalation is suspected. c. Make rapid head-to-toe assessment to rule out additional trauma. d. Stop the burning process and prevent further injury.

SWELLING

The injured limb should be kept elevated above the heart level to prevent and decrease ________

b

The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine output has dramatically increased. Which action by the nurse would best support maintaining kidney function? a. Monitor white blood cells (WBCs). b. Continue to measure the urine output. c. Assess that blisters and edema have subsided. d. Encourage the patient to eat an adequate number of calories.

3

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? 1 Application of autografts and daily sterile dressing changes 2 Twice-weekly wound cleaning and sterile dressing changes 3 Daily wound cleaning with debridement and sterile dressing changes 4 Daily wound cleaning with hydrotherapy and clean dressing changes

b

The nurse is assisting the patient to select foods from the menu that will promote wound healing. Which statement indicates the nurses knowledge of nutritional goals? a. Avoid foods that have saturated fats. Fats interfere with the ability of the burn wound to heal. b. Choose foods that are high in protein, such as meat, eggs, and beans. These help the burns to heal. c. It is important to choose foods like bread and pasta that are high in carbohydrates. These foods will give you energy and help you to heal faster. d. Select foods that have lots of fiber, such as whole grains and fruits. These will promote removal of toxins from the body that interfere with healing

C

The nurse is caring for a burn-injured patient who weighs 154 pounds, and the burn injury covers 50% of his body surface area. The nurse calculates the fluid needs for the first 24 hours after a burn injury using a standard fluid resuscitation formula of 4 mL/kg/% burn of intravenous (IV) fluid for the first 24 hours. The nurse plans to administer what amount of fluid in the first 24 hours? a. 2800 mL b. 7000 mL c. 14 L d. 28 L

B

The nurse is caring for a patient who has circumferential full-thickness burns of his forearm? A priority in the plan of care is : a. Keeping the extremity in a dependent position b. Active and passive range of motion every hour. c. Preparing for an escharotomy as a prophylactic measure d. Splinting the forearm

b

The nurse is caring for a patient who has undergone skin grafting of the face and arms for burn wound treatment. A primary nursing diagnosis is: a. altered nutrition, less than body requirements. b. body image disturbance. c. decreased cardiac output. d. fluid volume deficit.

a

The nurse is caring for a patient with a chemical burn injury. The priority nursing intervention is to: a. remove the patients clothes and flush the area with water. b. apply saline compresses. c. contact a poison control center for directions on neutralizing agents. d. remove all jewelry

d

The nurse is caring for a patient with an electrical injury. The nurse understands that patients with electrical injury are at a high risk for acute kidney injury secondary to: a. hypervolemia from burn resuscitation. b. increased incidence of ureteral stones. c. nephrotoxic antibiotics for prevention of infection. d. release of myoglobin from injured tissues.

a,b,d

The nurse is caring for a patient with burns to the hands, feet, and major joints. The nurse plans care to include which of the following? (Select all that apply.) a. Applying splints that maintain the extremity in an extended position b. Implementing passive or active range-of-motion exercises c. Keeping the limbs as immobile as possible d. Wrapping fingers and toes individually with bandages

4

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? 1 Full liquids only 2 Whatever the patient requests 3 High-protein and low-sodium foods 4 High-calorie and high-protein foods

A

The nurse is caring for patient who has been struck by lightning. Because of the nature of the injury, the nurse assesses the patient for which of the following? a. Central nervous system deficits b. Contractures c. Infection d. Stress ulcers

d

The nurse is planning care to meet the patients pain management needs related to burn treatment. The patient is alert, oriented, and follows commands. The pain is worse during the day when various treatments are scheduled. Which statement to the physician best indicates the nurses knowledge of pain management for this patient? a. Can we ask the music therapist to come by each morning to see if that will help the patients pain? b. The patients pain is often unrelieved. I suggest that we also add benzodiazepines to the opioids around the clock. c. The patients pain is often unrelieved. It would be best if we can schedule the opioids around the clock. d. The patients pain varies depending on the treatment given. Can we try patient-controlled analgesia to see if that helps the patient better?

D

The nurse is providing care to manage the pain of a patient with burns. The physician has ordered opiates to be given intramuscularly. The nurse contacts the physician to change the order to intravenous administration because: a. intramuscular injections cause additional skin disruption. b. burn pain is so severe it requires relief by the fastest route available. c. hypermetabolism limits effectiveness of medications administered intramuscularly. d. tissue edema may interfere with drug absorption of injectable routes.

2

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? 1 "If the area itches, I can apply a water-based moisturizer." 2 "After a month, I will be able to go to the beach to get a tan." 3 "I will need to wear the pressure garment for 24 hours a day." 4 "I will continue the range-of-motion exercises on a regular schedule."

c

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

b

The nurse understands that negative-pressure wound therapy may be used in the treatment of partial-thickness burn wounds to do which of the following? a. Maintain a closed wound system to decrease the risk of infection. b. Remove excessive wound fluid and promote moist wound healing. c. Increase patient mobility with large burn wounds. d. Quantify wound drainage amount for more accurate output assessment.

C

The optimal measurement of intravascular fluid status during the immediate fluid resuscitation phase of burn treatment is: a. blood urea nitrogen. b. daily weight. c. hourly intake and urine output. d. serum potassium.

C

The patient asks the nurse if the placement of the autograft over his full-thickness burn will be the only surgical intervention needed to close his wound. The nurses best response would be: a. Unfortunately, an autograft skin is a temporary graft and a second surgery will be needed to close the wound. b. An autograft is a biological dressing that will eventually be replaced by your body generating new tissue. c. Yes, an autograft will transfer your own skin from one area of your body to cover the burn wound. d. Unfortunately, autografts frequently do not adhere well to burn wounds and a xenograft will be necessary to close the wound.

2

The patient in the acute phase of burn care has electrical burns on the left side of the body, type 2 diabetes mellitus, and a serum glucose level of 485 mg/dL. What should be the nurse's priority intervention to prevent a life-threatening complication of hyperglycemia for this burned patient? 1 Maintain a neutral pH 2 Maintain fluid balance 3 Replace the blood lost 4 Replace serum potassium

3

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? 1 Sit or lie in a position of comfort 2 Wear a pressure garment for eight hours each day 3 Refer the patient to a counselor for psychosocial support 4 Use the sun to increase the skin color on the healed areas

b

The preferred type of IV fluid for fluid replacement in the emergent phase a. Hypertonic saline b. Lactated Ringers c. Colloids d. Albumin

full thickness burn

The structure B is fat, and structures C and D are muscle and bone, respectively. These three structures are involved in

C

Tissue damage from burn injury activates an inflammatory response that increases the patients risk for: a. acute kidney injury. b. acute respiratory distress syndrome. c. infection. d. stress ulcers.

blanching

Turning white

3,4,5

What are the clinical manifestations of a lower airway lung injury associated with burns? Select all that apply. 1 Edema 2 Blisters 3 Dyspnea 4 Wheezing 5 Altered mental status

1,4,5

When assessing a patient suffering from inhalation burns on the face and chest, what findings should a nurse anticipate? Select all that apply. 1 Increasing hoarseness 2 Location of contact points 3 Leathery white charred skin 4 Darkened oral or nasal membranes 5 Productive cough with black sputum

b

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

a

When assessing a patient with a deep partial thickness burns (2nd degree), what would the nurse expect to see? a. Shiny, red appearance b. Exposed muscle c. Dry, waxy appearance d. Burn rachae

2,4,5

When attending to a patient with severe burns, what precautions should the nurse take to maintain adequate nutrition? Select all that apply. 1 Assess respiratory rate every two hours. 2 Assess bowel sounds every eight hours. 3 Begin large amounts of feeding within first six hours. 4 Begin early enteral feeding with smaller-bore tubes. 5 Begin the feedings slowly at a rate of 20 to 40 mL/hr.

B

When paramedics notice singed hairs in the nose of a burn patient, it is recommended that the patient be intubated. What is the reasoning for the immediate intubation? a. Carbon monoxide poisoning always occurs when soot is visible. b. Inhalation injury above the glottis may cause significant edema that obstructs the airway. c. The patient will have a copious amount of mucus that will need to be suctioned. d. The singed hairs and soot in the nostrils will cause dysfunction of cilia in the airways.

d

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

3

Which burn injury results in tissue anoxia? 1 Thermal burn 2 Chemical burn 3 Electrical injury 4 Smoke and inhalational injury

2,5

Which clinical manifestations are observed in a patient in the emergent phase of a burn injury? Select all that apply. 1 Increased appetite 2 Increased heart rate 3 Increased urine output 4 Decreased respiratory rate 5 Decreased blood pressure

1

Which complication is caused by an electric burn? 1 Myoglobinuria 2 Systemic toxicity 3 Protein hydrolysis 4 Metabolic asphyxiation

a,b,d,e,g,h

Which complications may manifest after an electrical injury? (Select all that apply.) a. Long bone fractures b. Cardiac dysrhythmias c. Hypertension d. Compartment syndrome of extremities e. Dark brown urine f. Peptic ulcer disease g. Acute cataract formation h. Seizures

1,4

Which complications occur in a patient with metabolic asphyxiation? Select all that apply. 1 Hypoxia 2 Cardiac standstill 3 Protein hydrolysis 4 Hydrogen cyanide poisoning 5 Acute respiratory distress syndrome

4

Which fluid and electrolyte change occurs during the early emergent phase of burn injury? 1 Increased excretion of urine 2 Increased colloidal osmotic pressure 3 Return of interstitial fluid to the vascular space 4 Movement of sodium and water into interstitial fluids

c

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

b,c,e

Which of the following factors increase the burn patients risk for venous thromboembolism? (Select all that apply.) a. Burn injury less than 10% b. Bedrest c. Burns to lower extremities d. Electrical burn injury e. Delayed fluid resuscitation

A, c, e

Which of the following infection control strategies should the nurse implement to decrease the risk of infection in the burn-injured patient? (Select all that apply.) a. Apply topical antibacterial wound ointments/dressings. b. Change indwelling urinary catheter every 7 days. c. Daily assess the need for central IV catheters. d. Restrict family visitation. e. Maintain strict aseptic technique during burn wound management.

a,b,c

Which of the following statements about the pain management of a burn victim are true? (Select all that apply.) a. Additional pain medication may be needed because of rapid body metabolism. b. Pain medication should be given before procedures such as debridement, dressing changes, and physical therapy. c. Patients with a history of drug and alcohol abuse will require higher doses of pain medication. d. The intramuscular route is preferred for pain medication administration.

c

Which patient is most appropriate for the burn unit charge nurse to assign to a registered nurse (RN) who has floated from the hospital medical unit? a. A patient who has twice-daily burn debridements to partial-thickness facial burns b. A patient who has just returned from having a cultured epithelial autograft to the chest c. A patient who has a weight loss of 15% from admission and will have enteral feedings started d. A patient who has blebs under an autograft on the thigh and has an order for bleb aspiration

b

Which patient should the nurse assess first? a. A patient with burns who is complaining of level 8 (0 to 10 scale) pain b. A patient with smoke inhalation who has wheezes and altered mental status c. A patient with full-thickness leg burns who is scheduled for a dressing change d. A patient with partial thickness burns who is receiving IV fluids at 500 mL/hr

d

Which prescribed drug is best for the nurse to give before scheduled wound debridement on a patient with partial-thickness burns? a. ketorolac c. gabapentin (Neurontin) b. lorazepam (Ativan) d. hydromorphone (Dilaudid)

4

Which statement made by a student nurse regarding clinical manifestations associated with severe burns indicates the need for further education? 1 "The patient's altered mental status is due to hypoxia." 2 "The patient with larger burns may develop paralytic ileus." 3 "The patient with severe burns is most likely to be in shock." 4 "The patient is unconscious and cannot answer until intubated."

1,4,5

While assessing a patient with severe burns, the nurse suspects hypokalemia. What possible causes should the nurse evaluate? Select all that apply. 1 Vomiting 2 Renal failure 3 Adrenal insufficiency 4 IV therapy without potassium 5 Prolonged gastrointestinal (GI) suction

b

While the patient's full-thickness burn wounds to the face are exposed, what nursing action prevents cross contamination? a. Use sterile gloves when removing dressings. b. Wear gown, cap, mask, and gloves during care. c. Keep the room temperature at 70° F (20° C) at all times. d. Give IV antibiotics to prevent bacterial colonization of wounds.

3,4,5

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. 1 Avoid supplemental oxygen. 2 Prepare for discharge home. 3 Monitor for signs of complications. 4 Continue assessing oxygenation needs. 5 Continue to monitor respiratory status.

sterile gloves

_______________ should be worn when applying medications or dressings to a burn.

full thickness burn

a burn in which all the layers of the skin are damaged. There are usually areas that are charred black or areas that are dry and white. Also called a third-degree burn.

second degree burn

a deep partial thickness burn is also known as

c

a patient is to undergo skin grafting with the use of a cultured epitheal autografts for full thickness burns burns. the nurse explains to the patient that this treatment involves a. shaving a split thickness layer of the patients skin to cover the burn wound. b. using epidermal growth factor to cultivate cadaver skin for temporary wound coverage c. growing small specimens of the patient's skin into sheets to use as permanent skin coverage d. exposing animal skin to growth factors to decrease antigenicity so it can be used for permanent wound coverage.

Intraabdominal hypertension

a serious complication caused by circumferential torso burn injuries or edema from aggressive fluid resuscitation.

18%

abdomen percentage

Superficial Partial Thickness burn

aka 1st degree: only involves epidermis

Deep Partial thickness burn

aka 2nd degree: epidermis and dermis, skin is able to reproduce skin cells to heal spontaneously

Full thickness burns

aka 3rd & 4TH Degree burn: involves all skin, needs skin grafting

Argatroban

alternative to anticoagulants

warfarin, argatrobin, lepidurin, fonda

alternatives to heparin (WALF)

4.5%

anterior head burn percentage

4.5%

arm percentage

high protein, high carb calorie diet

burn diet

greater than 20%

carboxyhemoglobin level in a person with metabolic asphyxiation

Cytomegalovirus

common infection in organ transplantation, unpreventable

hipa test

confirms HIT

18-25 days

cultured epithelal autographs take how long to grow

epidermis

deep partial thickness burn involves

tissue anoxia, necrosis, spasms, bone fractures

electrical burns

Surface area, length of time, amount of voltage, tissue resistance and electrical pathways

electrical burns severity is caused by (SLATE)

partial thickness burn

epidermis and dermis are damaged

deep partial thickness burn

extends into the skin dermis and the wound is red and dry, with white areas in deeper parts; can convert to a full-thickness burn if tissue damage increases with infection, hypoxia, or ischemia

0.5-1ml/kh/hr , map greater than 65, sbp greater than 90, hr less than 120

fluid replacement critieria

crystalloids, LR

fluid replacement perferred is ___________ specifcically _____

third, fourth degree burns

full thickness burns are also known as

third, fourth

full thickness burns are also known as what degree

fat, muscle, bone

full thickness burns involve

90

goal is to have systolic greater than

c

he nurse is conducting an admission assessment of an 82-year-old patient who sustained a 12% burn from spilling hot coffee on the hand and arm. Which statement is of priority to assist in planning treatment? a. Do you live alone? b. Do you have any drug or food allergies? c. Do you have a heart condition or heart failure? d. Have you had any surgeries?

manifestations of lower airway injury

hoarseness, presence of facial burns, singed nasal hair, dark thick sputum, darkened oral and nasal membranes, wheezing, altered mental status

Saline, water

in acid burns, flush the chemical from the wound and surrounding area with copious amounts of _______solution or __________.

circulation

in burn patients check what first

around the clock

in burns give insulin

curlings

in burns there is a risk for this ulcer

Myoglobinuria, dysrhythmias and severe metabolic acidosis

in electrical injuries person is at risk for

Escharotomies

incisions through the eschar down to viable tissue to release the restriction and allow for chest expansion

x

know difference between grafts

full thickness burn

leathery eschar (dead tissue), dry, waxy, white, leathery, black eschar

9%

leg percentage

low protein, high calorie

liver diet

hoarseness, stridor

manifestations of upper airway

3-4%

normal carboxylate

35-45

normal hematocrit

12-18

normal hemoglobin

0.5-1

normal urine output

upper airway injury

rapid onset of massive swelling Edema, and eschar Manifestations: hoarseness; stridor, overproduction of secretions

Cultured epithelial autograft

skin grafts grown from biopsy specimens obtained from the patient's own skin.

Curling's ulcer

stress ulcer due to response to body's stress, over produce acid

superficial burn

such as sunburn, involves only the epidermis

hypoxia, nausea, vomitting, dyspnea, confusion

symptoms of smoke inhalation therapy

1

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? 1 Intravenous (IV) morphine sulfate 2 Subcutaneous (SQ) tetanus toxoid 3 Intramuscular (IM) hydromorphone 4 Oral (PO) oxycodone and acetaminophen

deep partial thickness burn

the structures involved are the epidermis and dermis to varying depths.

100% oxygen nonrebreather mask, prophylactic et tube

treatment for smoke inhalation injury

T-tube

tube placed in the bile duct for drainage into a small pouch (bile bag) on the outside of the body

circulation, airway, breathing

unresponsive burn patient order CAB

d

when monitoring initial fluid replacement for a 60kg patient with 40% TBSA deep partial thickness and full thickness burns, which finding is of most concern to the nurse? a. serum of 4.5 b. urine output of 45 ml/hr c. decreased bowel sounds d. blood pressure of 86/72 mm Hg

2nd degree burn

which burn is the most painful due to nerve endings still being intact?