Burns Ch.62 E2
A patient is being discharged after sustaining a deep-partial thickness burn during a house fire. The patient is asking when the burn will be healed. The nurse understands that this type of burn injury heals within which of the following time frames? a) 8 weeks b) 1 week c) 6 weeks d) 2 to 4 weeks
2 to 4 weeks Correct Explanation: For deep partial-thickness burn injuries, recovery is expected in 2 to 4 weeks.
A patient with a severe electrical burn injury is being treated in the burn unit. Which of the following laboratory results would cause the nurse the most concern? a) K+: 5.0 mEq/L b) BUN: 28 mg/dL c) Na+: 145 mEq/L d) Ca: 9 mg/dL
BUN: 28 mg/dL Correct Explanation: The elevated BUN would case the nurse the most concern. The nurse should report decreased urine output or increased BUN and creatinine values to the physician. These laboratory values indicate possible renal failure. In addition, myoglobinuria, which is associated with electrical burns, is common with muscle damage and may also cause kidney failure if not treated. The other values are within normal limits.
Burns Chapt. 62 PrepU
Burns Chapt. 62 PrepU
Which of the following actions is a quick assessment technique that the nurse might use to assess the percentage of a small or scattered burn injury? a) Checking the patient's vital signs b) Comparing the patient's palm with the size of the burn wound c) Observing the patient's level of consciousness d) Observing the color of the patient's wound
b
Which of the following topical burn preparations act as wick for sodium and potassium? a) Silver nitrate solution b) Silver sulfadiazine (Silvadene) c) Mafenide acetate (Sulfamylon) d) Acticoat
Silver nitrate solution Correct Explanation: Silver nitrate solution is hypotonic and acts as a wick for sodium and potassium. The other preparations do not act as a wick for sodium and potassium.
When using the palmar method to estimate the extent of the burn injury, the palm is equal to which percentage of TBSA? a) 3 b) .5 c) 4 d) 2
.5 Explanation: In patients with scattered burns, or for a quick prehospital assessment, the palmer method may be used to estimate the extent of the burns. The size of the patient's palm, not including the surface area of the digits, is approximately 0.5% of the TBSA
When using the Palmar method to estimate the extent of a small or scattered burn injury, the palm is equal to which percentage of total body surface area (TBSA)? a) 2 b) 4 c) 1 d) 3
1 Correct Explanation: In patients with scattered burns, or for a quick prehospital assessment, the Palmer method may be used to estimate the extent of the burns. The size of the patient's palm, not including the surface area of the digits, is approximately 1% of the TBSA.
A patient has undergone grafting following a burn injury. The nurse understands that the first dressing change at the site of an autograft is performed how soon after the surgery? a) Within 12 hours after surgery b) As soon as sanguineous drainage is noted c) 2 to 5 days after surgery d) Within 24 hours after surgery
2 to 5 days after surgery Explanation: The first dressing change usually occurs 2 to 5 days after surgery. In addition, a foul odor or purulence may indicate infection and should be reported to the surgeon immediately. Sanguineous drainage on a dressing covering an autograft is an anticipated abnormal observation postoperatively.
Several temporary and permanent sources are available for covering a burn wound. These may be manufactured synthetically, obtained from a biologic source, or a combination of the two. Select the graft described as the following: a biologic source of skin similar to that of the client. a) Autograft b) Allograft c) Xenograft d) Slit graft
Allograft Explanation: Allograft or homograft is a biologic source of skin similar to that of the client. A xenograft or heterograft is obtained from animals, principally pigs or cows. An autograft uses the client's own skin, transplanted from one part of the body to another. A slit graft is a type of autograft.
Which of the following measures can be used to cool a burn? a) Using cold soaks or dressings for at least 1 hour b) Application of cool water c) Wrapping the person in ice d) Application of ice directly to burn
Application of cool water Explanation: Once a burn has been sustained, the application of cool water is the best first-aid measure. Never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns.
A patient is brought to the ED by a coworker following a burn injury from a high-voltage electrical power line. The triage nurse will complete which of the following interventions first? a) Take the patient's vital signs. b) Obtain a 12-lead ECG. c) Insert a urinary Foley catheter. d) Apply a cervical collar on the patient.
Apply a cervical collar on the patient. Correct Explanation: Until it is known that the patient has no fractures, it is imperative that a neck collar be applied and remain in place and that the patient is log rolled to eliminate the chance of further spinal cord injury. With high-voltage electrical injuries, cervical spine immobilization is a priority until cervical spine injury is ruled out. The other interventions may be completed; however, the priority intervention is to apply the collar.
Tom Benson, a 42-year-old electrical lineman, suffered significant burns in a workplace accident. During his airlift to a regional burn unit, you assess his wounds taking care to find and mark his entrance and exit wounds. What occurrence makes it difficult to assess internal burn damage in electrical burns? a) Protein cell coagulation b) All options are correct. c) Continuing inflammatory process d) Deep tissue cooling
Deep tissue cooling Explanation: Because deep tissues cool more slowly than those at the surface, it is difficult initially to determine the extent of internal damage.
Molly Baker has a third-degree burn on her leg from a house fire. The wound is being treated by the open method. After about 4 days, a hard crust has formed around the leg and is impairing the circulation to her leg. What procedure would be done to relieve pressure on the affected area? a) Allograft b) Escharotomy c) Silvadene application d) Debridement
Escharotomy Correct Explanation: Debridement is the removal of necrotic tissue. An escharotomy is an incision into the eschar to relieve pressure on the affected area. An allograft would not be the treatment. Silvadene may be part of the treatment regimen but not specifically for this situation.
A 6-year-old girl was playing near her family's campfire when she fell into the fire, suffering significant burns. She was taken by air ambulance to the burn unit where you practice nursing. What physiologic process furthers her burn injury? a) Inflammatory b) Intravascular fluid excess c) Neuroendocrine d) Hypertension
Inflammatory Correct Explanation: The initial burn injury is further extended by inflammatory processes that affect layers of tissue below the initial surface injury.
The nurse is caring for a patient with superficial partial-thickness burn injuries to the lower extremities. The patient is ordered IV morphine for pain. The nurse understands narcotics are given IV to manage pain during the initial management of pain because of which of the following? a) Tissue edema may interfere with drug absorption via other routes. b) The patient can experience nausea and emesis when given oral medications. c) Bleeding may occur at injection sites when the intramuscular route is used. d) Pain resulting from a burn injury requires relief by the fastest route available.
Tissue edema may interfere with drug absorption via other routes. Explanation: IV administration is necessary because of altered tissue perfusion from the burn injury.
Which type of debridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar? a) Chemical debridement b) Mechanical debridement c) Natural debridement d) Surgical debridement
Mechanical debridement Explanation: Mechanical debridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar. Topical enzymatic debridement agents are available to promote debridement of the burn wounds. With natural debridement, the dead tissue separates from the underlying viable tissue spontaneously. Surgical debridement is an operative procedure involving either primary excision (surgical removal of tissue) of the full thickness of the skin down to the fascia (tangential excision) or shaving of the burned skin layers gradually down to freely bleeding, viable tiss
A patient has been prescribed Acticoat as a burn wound treatment. Which of the following is accurate regarding application of Acticoat? a) Moisten with sterile water only. b) Moisten with saline. c) Keep Acticoat saturated. d) Use topical antimicrobials with Acticoat burn dressing.
Moisten with sterile water only. Explanation: Acticoat is moistened with sterile water only; never use normal saline. Do not use topical antimicrobials with Acticoat burn dressing. Keep Acticoat moist, not saturated.
Which of the following is the analgesic of choice for burn pain? a) Fentanyl b) Demerol c) Tylenol with codeine d) Morphine sulfate
Morphine sulfate remains the analgesic of choice. It is titrated to obtain pain relief on the patient's self-report of pain. Fentanyl is particularly useful for procedural pain, because it has a rapid onset, high potency, and short duration, all of which make it effective for use with procedures. Demerol and Tylenol with codeine are not analgesics of choice for burn pain.
A patient has been prescribed mafenide acetate (Sulfamylon) cream for burn treatment. The nurse should educate the patient regarding which of the following? a) Stains clothing b) Severe burning pain for up to 20 minutes c) Blood levels of sodium and potassium will be monitored. d) Can be left in place for 3 to 5 days
Severe burning pain for up to 20 minutes Explanation: The patient should be premedicated with analgesic before applying mafenide acetate because this agent causes severe burning pain for up to 20 minutes after application. Silver nitrate stains everything it touches black. Acticoat dressings can be left in place for 3 to 5 days. Silver nitrate solution acts as a wick for sodium and potassium; serum levels of these electrolytes need to be monitored
All of the following are antimicrobials commonly used to treat burns except: a) Tetracycline b) Silver sulfadiazine (Silvadene) c) Mafenide (Sulfamylon) d) Silver nitrate (AgNO3) 0.5% solution
Tetracycline Correct Explanation: Silver sulfadiazine (Silvadene), mafenide (Sulfamylon), and silver nitrate (AgNO3) 0.5% solution are the three major antimicrobials used to treat burns.
A patient with a burn wound is prescribed mafenide acetate 5% (Sulfamylon) twice daily. Nursing implications associated with this medication include which of the following? a) Premedicating the patient with an analgesic prior to application b) Monitoring the patient's Na+ and K+ serum levels and replace as prescribed c) Monitoring the patient for the development of respiratory acidosis d) Protecting the bed linens and patient's clothing from contact to prevent staining
Premedicating the patient with an analgesic prior to application Correct Explanation: Mafenide is a strong carbonic anhydrase inhibitor and may cause metabolic acidosis. Application may cause considerable pain initially, thus premedicating the patient is an appropriate intervention. The other nursing implications are not associated with mafenide.
Which of the following fluid or electrolyte changes occur in the emergent/resuscitative phase? a) Reduction in blood volume b) Sodium excess c) Increased urinary output d) Potassium deficit
Reduction in blood volume Correct Explanation: A reduction in blood volume occurs secondary to plasma loss. Sodium deficit, potassium excess, and decreased urinary output occurs in this phase.
Which of the following are possible indicators of pulmonary damage from an inhalation injury? Select all that apply. a) Facial burns b) Yellow sputum c) Hoarseness d) Singed nasal hair e) Bradypnea
• Singed nasal hair • Hoarseness • Facial burns Explanation: Indicators of possible pulmonary damage include singed nasal hair, hoarseness, voice change, stridor, burns of the face or neck, sooty or bloody sputum, and tachypnea.
Acticoat antimicrobial barrier dressings used in the treatment of burn wounds can be left in place for which timeframe?
5 days
Which of the following complications is common for victims of electrical burns? a) Inhalation injury b) Infection c) Hypovolemic shock d) Cardiac dysrhythmia
Cardiac dysrhythmia Correct Explanation: Cardiac dysrhythmias are common for victims of electrical burns. If the patient has an electrical burn, a baseline electrocardiogram (ECG) is obtained and continuous monitoring is initiated. Any burn injury can lead to complications, such as inhalation injury, infection, and hypovolemic shock.
Within the practice of nursing at the burn unit, there are specific potential complications common to specific types of burns. Which burns can impair ventilation? a) Face, neck, chest b) Perineal c) All options are correct. d) Hands, major joints
Face, neck, chest Correct Explanation: Burns of the face, neck, or chest have the potential to impair ventilation.
Bill Jenkins has suffered from a burn on his leg related to an engine fire. Burn depth is determined by assessing the color, characteristics of the skin, and sensation in the area. When the burn area was assessed, it was determined that he felt no pain in the area and that it appeared charred. What depth of burn injury would he be said to have? a) Fourth degree b) Superficial (first degree) c) Full thickness (third degree) d) Superficial partial-thickness and deep partial-thickness (second degree)
Full thickness (third degree) Explanation: Full-thickness (third degree) burn destroys all layers of the skin and consequently is painless. The tissue appears charred or lifeless. Superficial (first degree) burn is similar to a sunburn. The epidermis is injured, but the dermis is unaffected. Superficial partial-thickness burn heals within 14 days, with possibly some pigmentary changes but no scarring. The deep partial-thickness (second degree) burn takes more than 3 weeks to heal, may need debridement, and is subject to hypertrophic scarring. A fourth-degree burn can involve ligaments, tendons, muscles, nerves, and bone.
Which of the following is the preferred IV fluid for burn resuscitation? a) Lactated Ringer's (LR) b) D5W c) Total parenteral nutrition (TPN) d) Normal saline (NS)
Lactated Ringer's (LR) Correct Explanation: LR is the preferred IV fluid for burn resuscitation because the sodium concentration and potassium are similar to normal intravascular levels. NS, D5W, and TPN are not the IV of choice for burn resuscitation.
The nurse is caring for a patient in the burn unit. Which of the following may be an early sign of sepsis in the patient with burn injury? a) Clammy skin b) Decreased pulse rate c) Hyperthermia d) Narrowing pulse pressure
Narrowing pulse pressure Explanation: Patients with burns are hypermetabolic. This results in tachycardia, tachypnea, and elevated body temperature. These physiological norms in patients with burns make the diagnosis of sepsis more challenging. The signs of early systemic sepsis are subtle and require a high index of suspicion and very close monitoring of changes in the patient's status. Early signs of sepsis may include increased temperature, increased pulse rate, widened pulse pressure, and flushed dry skin in unburned areas.
Which of the following is a potential cause of a superficial partial-thickness burn? a) Scald b) Flash flame c) Sunburn d) Electrical current
Sunburn Correct Explanation: A potential cause of a superficial partial-thickness burn is a sunburn or low-intensity flash. Causes of deep partial-thickness burns are scalds and flash flames. Full-thickness burns may be caused by an electrical current or prolonged exposure to hot liquids.
Which of the following is the key sign of onset of ARDS? a) Tachypnea b) Stridor c) Hypoxemia d) Chest pain
hypoxemia Explanation: The key sign of the onset of ARDS is hypoxemia while receiving 100% oxygen, with decreased lung compliance and significant shunting. The physician should be notified immediately of deteriorating respiratory status.
A patient is being cared for in a burn unit after suffering partial-thickness burns. The patient's laboratory work reveals a positive wound culture for gram-negative bacteria. The health care provider orders silver sulfadiazine (Silvadene) to be applied to the patient's burns. The nurse provides information to the patient about the medication. Which of the following statements made by the patient indicates an understanding about this treatment? Select all that apply. a) "This medication is an antibacterial." b) "This medication will stain my skin permanently." c) "This medication will help my burn heal." d) "This medication will be applied directly to the wound."
"This medication is an antibacterial." • "This medication will help my burn heal." • "This medication will be applied directly to the wound." Correct Explanation: This medication is an antibacterial, which has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. This medication is directly applied to the wound. This medication will not stain the patient's skin, but it will help heal the patient's burned areas.
A patient presents to the ED following a burn injury. The patient has burns to the anterior chest and entire left leg. Using the rule of nines, the nurse documents the total body surface area (TBSA) percentage as which of the following? a) 9% b) 36% c) 18% d) 27%
36% (questionable) Explanation: The rule-of-nines system is based on dividing anatomic regions, each representing approximately 9% of the TBSA, quickly allowing clinicians to obtain an estimate. If a portion of an anatomic area is burned, the TBSA is calculated accordingly—for example, if approximately half of the anterior leg is burned, the TBSA burned would be 4.5%. More specifically, with an adult who has been burned, the percent of the body involved can be calculated as follows: head = 9%, chest (front) = 9%, abdomen (front) = 9%, upper/mid/low back and buttocks = 18%, each arm = 9% (front = 4.5%, back = 4.5%), groin = 1%, and each leg = 18% total (front = 9%, back = 9%).
Following a burn injury, which of the following areas is the priority for nursing assessment? a) Pulmonary system b) Cardiovascular system c) Nutrition d) Pain
Airway patency and breathing must be assessed during the initial minutes of emergency care. Immediate therapy is directed toward establishing an airway and administering humidified 100% oxygen. Pulmonary problems may be caused by the inhalation of heat and/or smoke or edema of the airway. Assessing a patent airway is always a priority after a burn injury followed by breathing. Remember the ABCs.
The most important intervention in the nutritional support of a patient with a burn injury is to provide adequate nutrition and calories to promote which of the following? a) Increased metabolic rate b) Increased skeletal muscle breakdown c) Decreased catabolism d) Increased glucose demands
Decreased catabolism Correct Explanation: Burn injuries produce profound metabolic abnormalities fueled by the exaggerated stress response to the injury. The body's response has been classified as hyperdynamic, hypermetabolic, and hypercatabolic. The most important intervention in the nutritional support of a patient with a burn injury is to provide adequate nutrition and calories to decrease catabolism. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50%. A marked increase in metabolic rate is seen after a burn injury and interventions are instituted to decrease metabolic rate and catabolism. A marked increase in glucose demand is seen after a burn injury and interventions are instituted to decrease glucose demands and catabolism. Rapid skeletal muscle breakdown with amino acids serving as the energy source is seen after a burn injury and interventions are instituted to decrease catabolism.
When the emergency nurse learns that the patient suffered injury from a flash flame, the nurse anticipates which depth of burn? a) Full thickness b) Deep partial thickness c) Superficial partial thickness d) Superficial
Deep partial thickness Explanation: A deep partial thickness burn is similar to a second-degree burn and is associated with scalds and flash flames. Superficial partial thickness burns are similar to first-degree burns and are associated with sunburns. Full thickness burns are similar to third-degree burns and are associated with direct flame, electric current, and chemical contact. Injury from a flash flame is not associated with a burn that is limited to the epidermis.
Which type of burn injury involves destruction of the epidermis and upper layers of the dermis and injury to the deeper portions of the dermis? a) Fourth degree b) Full-thickness c) Deep partial-thickness d) Superficial partial-thickness
Deep partial-thickness Correct Explanation: A deep partial-thickness burn involves destruction of the epidermis and upper layers of the dermis and injury to deeper portions of the dermis. In a superficial partial-thickness burn, the epidermis is destroyed or injured and a portion of the dermis may be injured. Capillary refill follows tissue blanching. Hair follicles remain intact. A full-thickness burn involves total destruction of epidermis and dermis and, in some cases, destruction of underlying tissue, muscle, and bone. Although the term fourth-degree burn is not used universally, it occurs with prolonged flame contact or high voltage injury that destroys all layers of the skin and damages tendons and muscles.
A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following? a) Superficial partial-thickness b) Superficial c) Full-thickness d) Deep partial-thickness
Full-thickness Correct Explanation: A full-thickness burn involves total destruction of the dermis and extends into the subcutaneous fat. It can also involve muscle and bone. A superficial burn only damages the epidermis. In a superficial partial-thickness burn, the epidermis is destroyed and a small portion of the underlying dermis is injured. A deep partial-thickness burn extends into the reticular layer of the dermis and is hard to distinguish froma full-thickness burn. It is red or white, mottled, and can be moist or fairly dry
Which of the following provides clues about fluid volume status? Select all that apply.
Hourly urine output • Daily weights Explanation: Monitoring of hourly urine output and daily weights provides clues about fluid volume status. Percentage of meals eaten, skin turgor, and oxygen saturation would not be reliable indicators of fluid volume status in the burn injured patient.
The nurse is providing care for a patent with a full-thickness, circumferential burn of the left lower leg. During the nurse's initial shift assessment, the patient is resting and the physical assessment of the left lower extremity is unremarkable. One hour later, the nurse notes the pulses of the left lower leg cannot be obtained by a Doppler ultrasound device, and the capillary refill of the left great toe is greater than 2 seconds. The nurse's best response based on the clinical findings is which of the following? a) Apply an elastic stocking to the extremity and administer SQ heparin per order. b) Document the findings and instruct the patient to report numbness of the extremity. c) Contact the primary care provider and prepare for an escharotomy. d) Elevate the leg on pillows and reassess the leg in 1 hour.
You selected: Contact the primary care provider and prepare for an escharotomy. Correct Explanation: The nurse assesses peripheral pulses frequently with a Doppler ultrasound device, if needed. Frequent assessment also includes warmth, capillary refill, sensation, and movement of extremity. It is necessary for the nurse to report loss of pulse or sensation or presence of pain to the physician immediately and to prepare to assist with an escharotomy. The other interventions are inappropriate when the nurse has detected a loss of peripheral pulses.
The nurse understands that during the emergent/resuscitative phase of burn injury, hemoconcentration is due to which of the following? a) Liquid blood component is lost into extravascular space b) Fluid loss c) Decreased renal blood flow d) Sodium and water retention caused by increase adrenocortical activity
You selected: Liquid blood component is lost into extravascular space Correct Explanation: Hemoconcentration is due to the blood component being lost into the extravascular space. Decreased urinary output occurs secondary to fluid loss, decreased renal blood flow, and sodium and water retention caused by increased adrenocortical activity.
Determining the depth of a burn is difficult initially because there are combinations of injury zones in the same location. The following describes one of the injury zones: the area of intermediate burn injury. It is here that blood vessels are damaged, but tissue has the potential to survive. What is the name of that zone? a) Zone of stasis b) Zone of coagulation c) Zone of hyperemia d) Zone of hypotension
Zone of stasis Explanation: The zone of stasis is the area of intermediate burn injury. It is here that blood vessels are damaged, but tissue has the potential to survive. The zone of coagulation is at the center of the injury, and it is the area where the injury is most severe and usually deepest. The zone of hyperemia is the area of least injury, where the epidermis and dermis are only minimally damaged. This is not the name of one of the zones.
A 42-year-old client suffered significant burns in a workplace accident. During his airlift to a regional burn unit, you assess his wounds taking care to find and mark his entrance and exit wounds. Which of the following conditions create the need for intensive care by specifically trained personnel? a) Fluid shift b) Fluid loss c) All options are correct. d) Hypotension
• All options are correct. • Fluid shift • Fluid loss • Hypotension Explanation: Fluid shift, fluid loss, and hypotension can lead to irreversible shock. These changes usually happen rapidly and the client's status may change from hour to hour, requiring that clients with burns receive intensive care by skilled personnel.
Which of the following is to be expected soon after a major burn? Select all that apply. a) Bradycardia b) Anxiety c) Hypertension d) Hypotension e) Tachycardia
• Anxiety • Hypotension • Tachycardia Correct Explanation: Tachycardia, slight hypotension, and anxiety are expected soon after the burn.
The nurse is caring for a patient with extensive burn injuries. Which of the following parameters would the nurse evaluate to determine if the patient is receiving adequate fluid resuscitation? Select all that apply. a) Heart rate b) Urine output c) Oxygen saturation d) Blood pressure
• Blood pressure • Heart rate • Urine output Explanation: Fluid resuscitation is administered to maintain adequate cardiac output and tissue perfusion. If adequate fluid is administered, tachycardia, hypotension, and oliguria will resolve. Expected outcomes of fluid resuscitation specifically include the following: urine output between 0.5 and 1.0 mL/kg/hr (30-50 mL/hr; 75 to 100 mL/hr if electrical burn injury), mean arterial pressure (MAP) pressure > 60 mm Hg, voids clear yellow urine with specific gravity within normal limits, and serum electrolytes are within normal limits
At the scene of a fire, the first priority is to prevent further injury. What are interventions at the site that can help to prevent injury? Choose all that apply. a) Open door and encourage air in an enclosed space. b) Place the client in a horizontal position. c) Place the client in a vertical position. d) Roll the client in a blanket to smother the fire.
• Place the client in a horizontal position. • Roll the client in a blanket to smother the fire. Explanation: If the clothing is on fire, the client is placed in a horizontal position and rolled in a blanket to smother the fire.
The nurse is caring for a 30-year-old female patient who suffered severe head and facial burn injuries. Which of the following actions, if completed by the patient, indicates she is adapting to her altered body image? Select all that apply. a) Reports absence of sleep disturbance b) Wears hats and wigs c) Covers her face with a scarf d) Participates actively in daily activities
• Wears hats and wigs • Participates actively in daily activities Correct Explanation: The following are indicators that a patient is adapting to altered body image: verbalizes accurate description of alterations in body image and accepts physical appearance, demonstrates interest in resources that may improve function and perception of body appearance (e.g., uses cosmetics, wigs, and prostheses, as appropriate); socializes with significant others, peers, and usual social group; and seeks and achieves return to role in family, school, and community as a contributing member. Covering the face with a scarf indicates the patient is not adapting to the alteration in body image; absence of sleep disturbances is expected by the burn-injured patient but is not related to body image disturbance.
