BURNS EVERYTHING (PART 2)
28. A male patient, 16 years old, comes to the emergency department (ED) after burning his right hand and arm while working on a friend's car. The injury is determined to be a superficial burn and it is treated. What would the nurse teach the patient before discharging him home to return on a daily basis for dressing changes? A) "As your arm swells, push on your fingernails. If it takes longer than 5 seconds for them to get pink come back to the ED." B) "You should be fine until you come back tomorrow for your dressing change." C) "Drink lots of fluids and elevate the arm." D) "The burned area will start to swell in about 4 hours and blisters will form. If you think the dressing is too tight come back to the ED."
"The burned area will start to swell in about 4 hours and blisters will form. If you think the dressing is too tight come back to the ED." **In a superficial burn there is loss of capillary integrity and fluid is localized to the burn itself, resulting in blister formation and edema only in the area of injury. Capillary refill should be 3 seconds or less. Options B and C are distracters for this question.
17. A patient arrives in the emergency department after being burned in a house fire. The patient's burns cover the face and the left forearm. What percentage of burn does the patient have? A) 10% B) 25% C) 9% D) 18%
18% **When estimating the percentage of body area or burn surface area that has been burned, the Rule of Nines is used: the face is 9%, and the forearm is 9% for a total of 18% in this patient.
6. The emergency department nurse has just admitted a patient with a burn. The nurse recognizes that the patient is likely to experience a local and systemic response to the burn when the burn exceeds a total body surface area (TBSA) of what? A) 10% B) 15% C) 20% D) 25%
25% **If the burn exceeds 20% to 25% TBSA, a nasogastric tube is inserted and connected to low intermittent suction. Often, patients with large burns become nauseated as a result of the gastrointestinal effects of the burn injury, such as paralytic ileus, and the effects of medication such as opioids. All patients who are intubated should have a nasogastric tube inserted to decompress the stomach and prevent vomiting.
24. You have just reported to the burn unit to start your shift. Four new patients have been admitted in the past 12 hours. Which patient is most likely to have life-threatening complications? A) A 4-year-old scald victim burned over 24% of the body B) A 27-year-old healthy male burned over 36% of his body in a car accident C) A 39-year-old female with myasthenia gravis burned over 18% of her body D) A 60-year-old male burned over 16% of his body in a brush fire
A A 4 YEAR OLD SCALD VICTIM BURNED OVER 24% FO THE BODY **Young children and the elderly continue to have increased morbidity and mortality when compared to other age groups with similar injuries and present a challenge for burn care. This is an important factor when determining the severity of injury and possible outcome for the patient.
23. A 45-year-old man is brought in by Life-Flight after a motor vehicle accident is which he was trapped in a burning vehicle. The burn team is estimating the patient's likelihood of survival based on the severity of the burn injury. The emergency department nurse knows that the severity of the injury is based on what factors? (Mark all that apply.) A) Age B) Depth of the burn C) Presence of inhalation injury D) Family support E) Psychological state of the patient
A, B, C AGE, DEPTH OF THE BURN, PRESENCE OF INHALATION INJURY **The severity of each burn injury is determined by multiple factors that when assessed help the burn team estimate the likelihood that a patient will survive and plan the care for each patient. These factors include age of the patient; depth of the burn; amount of surface area of the body that is burned; presence of inhalation injury; presence of other injuries; location of the injury in special care areas such as the face, perineum, hands, and feet; and presence of a past medical history. Options D and E are not factors that bear on the severity of the injury.
A patient in the rehabilitation phase of the burn injury is setting goals with the nurse. What goals would be appropriate at this time? (Mark all that apply.) A) Increased participation in activities of daily living B) Increased understanding of the planned follow-up care C) Increased control of treatment D) Adjustment to alterations in lifestyle E) Recognition of complications
A, B, D INCREASED PARTICIPATION IN ADLs, INCREASED UNDERSTANDING OF THE PLANNED FOLLOW-UP CARE, ADJUSTMENT TO ALTERATIONS IN LIFESTYLE **The major goals for the patient include increased participation in activities of daily living; increased understanding of the injury, treatment, and planned follow-up care; adaptation and adjustment to alterations in body image, self-concept, and lifestyle; and absence of complications.
16. A patient is brought to the ED by paramedics who report the patient has partial-thickness burns on the chest and legs. The patient has also suffered smoke inhalation. What is a priority in the care of a patient who has been burned and suffered smoke inhalation? A) Pain B) Fluid balance C) Anxiety and fear D) Airway management
AIRWAY MANAGEMENT **Systemic threats from a burn are the greatest threat to life. The ABCs of all trauma care apply during the early postburn period. While all options should be addressed, pain, fluid balance, and anxiety and fear do not take precedence over airway management.
10. The nurse is preparing the patient for mechanical debridement and informs the patient that this will involve: A) A spontaneous separation of dead tissue from the viable tissue B) Use of surgical scissors, scalpels or forceps to remove the eschar until the point of pain and bleeding occurs C) Shaving of burned skin layers until bleeding, viable tissue is revealed D) Early closure of the wound
B USE OF SURGICAL SCISSORS, SCALPELS OR FORCEPS TO REMOVE THE ESCHAR UNTIL THE POINT OF PAIN AND BLEEDING OCCURS **Mechanical debridement can be achieved through the use of surgical scissors, scalpels, or forceps to remove the eschar until the point of pain and bleeding occurs. Mechanical debridement can also be accomplished through the use of topical enzymatic debridement agents. The spontaneous separation of dead tissue from the viable tissue is an example of natural debridement. Early wound closure and shaving the burned skin layers are examples of surgical debridement.
nurse taking care of a burn patient is asked why the patient is losing so much weight. What would be the nurse's most appropriate answer? A) "Your body has built up extra fat deposits even though you haven't been eating very much." B) "Your body has used your fat deposits for fuel because you haven't been eating very much." C) Your reserve fat deposits have been catabolized because you have been eating so much." D) You have lost fluids and you haven't eaten very much."
B YOUR BODY HAS USED YOUR FAT DEPOSITS FOR FUEL BECAUSE YOU HAVEN'T BEEN EATING VERY MUCH **Patients lose a great deal of weight during recovery from severe burns. Reserve fat deposits are catabolized, fluids are lost, and caloric intake may be limited.
32. As the patient begins the acute phase of a burn, cautious administration of fluids and electrolytes continues. The nurse knows that this caution is because of what? (Mark all that apply.) A) Patient is considered in critical condition B) Cardiac function is decreased C) Patient's physiologic responses to the burn injury D) Losses of fluid from large burn wounds E) Shifts in fluid from the interstitial to the intravascular compartment
C) Patient's physiologic responses to the burn injury D) Losses of fluid from large burn wounds E) Shifts in fluid from the interstitial to the intravascular compartment **Cautious administration of fluids and electrolytes continues during this phase of burn care because of the shifts in fluid from the interstitial to the intravascular compartment, losses of fluid from large burn wounds, and the patient's physiologic responses to the burn injury.
12. An emergency department nurse learns from the paramedics that they are transporting a patient who has suffered injury from a scald from a hot kettle. What factors does the nurse know are considered when determining the depth of burn? A) Causative agent B) Visual observation of burned area C) Area of body burned D) Circumstances of the accident
CAUSATIVE AGENT **The following factors are considered in determining the depth of a burn: how the injury occurred, causative agent (such as flame or scalding liquid), temperature of the burning agent, duration of contact with the agent, and thickness of the skin. To determine the depth of the burn you do not take into consideration you visual observation of the burned area, how much of the body is burned, or the circumstances of the accident.
34. A nurse is caring for a patient during the acute phase of the burn. The nurse knows he is responsible for what? A) Restricting visitors to prevent infection B) Closely scrutinizing the burn wound to detect early signs of infection C) Cleaning the patient's room D) Maintaining the patient in a sterile environment
CLOSELY SCRUTINIZING THE BURN WOUND TO DETECT EARLY SIGNS OF INFECTION **The nurse is responsible for providing a clean and safe environment and for closely scrutinizing the burn wound to detect early signs of infection. Visitors are not restricted to a burn patient. The nurse does not clean the patient's room. The patient is maintained in a clean environment, not a sterile environment.
The nurse is teaching a patient with a partial-thickness wound how to wear his elastic pressure garment. How would the nurse instruct the patient to wear this garment? A) 4 to 6 hours a day for 6 months B) Daily for 2 to 3 months after the injury C) Continuously D) At night while sleeping for a year after the injury
CONTINUOUSLY Garments are worn continuously (ie, 23 hours a day).
The injury that is least likely to result in a full-thickness burn is: a. sunburn b. scald injury c. chemical burn d. electrical injury
Correct answer: a Rationale: Full-thickness burns may be caused by contact with flames, scalding liquids, chemicals, tar, or electrical current.
A therapeutic measure used to prevent hypertrophic scarring during rehabilitation phase of burn recover is: a. applying pressure garments b. repositioning the patient every 2 hours c. performing active ROM at least every 4 hours d. massaging the new tissue with water-based moisturizers
Correct answer: a Rationale: Pressure can help keep a scar flat and reduce hypertrophic scarring. Gentle pressure can be maintained on the healed burn with custom-fitted pressure garments.
To maintain a positive nitrogen balance in a major burn, the patient must: a. eat a high-protein, low-fat, high-carbohydrate diet b. increase normal caloric intake by about three times c. eat at least 1500 calories/day in small, frequent meals d. eat rice and whole wheat for the chemical effect on nitrogen balance.
Correct answer: a Rationale: The patient should be encouraged to eat high-protein, high-carbohydrate foods to meet increased caloric needs. Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. Failure to supply adequate calories and protein leads to malnutrition and delays in healing.
A patient has 25% TBSA burned from a car fire. His wounds have been debrided and covered with a silver-impregnated dressing. The nurse's priority intervention for wound care would be to: a. reapply a new dressing without disturbing the wound bed b. observe the wound for signs of infection during dressing changes c. apply cool compresses for pain relief in between dressing changes d. wash the wound aggressively with soap and water three times a day.
Correct answer: b Rationale: Infection is the most serious threat with regard to further tissue injury and possible sepsis.
Fluid and electrolyte shifts that occur during the early emergent phase of a burn injury include: a. adherence of albumin to vascular walls b. movement of potassium into vascular space c. sequestering of sodium and water in interstitial fluid d. hemolysis of red blood cells from large volumes of rapidly administered fluid
Correct answer: c Rationale: During the emergency phase, sodium rapidly shifts to the interstitial spaces and remains there until edema formation ceases.
A patient is recovering from second- and third-degree burns over 30% of his body and is now ready for discharge. The first action the nurse should take when meeting with the patient would be to: a. arrange a return-to-clinic appointment and prescription for pain medications b. teach the patient and caregiver proper wound care to be performed at home c. review the patient's current health care status and readiness for discharge to home d. give the patient written discharge information and websites for additional information for burn survivors.
Correct answer: c Rationale: Recovery from a burn injury to 30% of total body surface area (TBSA) takes time and is exhausting, both physically and emotionally, for the patient. The health care team may think that a patient is ready for discharge, but the patient may not have any idea that discharge is being contemplated in the near future. Patients are often very fearful about how they will manage at home. The patient would benefit from the nurse's careful review of his or her progress and readiness for discharge; then the nurse should outline the plans for support and follow-up after discharge.
A patient is admitted to the burn center with burns of his head and neck, chest, and back after an explosion in his garage. On assessment, the nurse auscultates wheezes throughout the lung fields. On reassessment, the wheezes are gone and the breath sounds are greatly diminished. Which action is the most appropriate for the nurse to take next? a. obtain vital signs and a STAT ABG b. encourage the patient to cough and auscultate the lungs again c. document the findings and continue to monitor the patient's breathing d. anticipate the need for endotracheal intubation and notify the physician
Correct answer: d Rationale: Inhalation injury results in exposure of the respiratory tract to intense heat or flames with inhalation of noxious chemicals, smoke, or carbon monoxide. The nurse should anticipate the need for intubation and mechanical ventilation because this patient is demonstrating signs of severe respiratory distress.
Pain management for the burn patient is most effective when (SATA): a. a pain rating tool is used to monitor the patient's level of pain b. painful dressing changes are delayed until the patient's pain is completely relieved c. the patient is informed about and has some control over the management of the pain d. a multi-modal approach is used (e.g., sustained-release and short-acting opioids, NSAIDS, adjuvant analgesics). e. non-pharmacological therapies (e.g., music therapy, distraction) replace opioids in the rehabilitation phase of a burn injury
Correct answers: a, c, d Rationale: The use of a pain rating tool assists the nurse in the assessment, monitoring, and evaluation of the pain management plan. The more control the patient has in managing the pain, the more successful the chosen strategies are. A selected variety of medications offer better pain relief for patients with burns, whose pain can be both continuous and treatment related over varying periods of time. It is not realistic to promise a patient that pain will be completely eliminated. It is not realistic to suggest that pain will be managed (during any phase of burn care) with nonpharmacologic pain management. Such management is meant to be adjuvant and individualized.
When assessing a patient with a partial-thickness burn, the nurse would expect to find (SATA): a. blisters b. exposed fascia c. exposed muscles d. intact nerve endings e. red, shiny, wet appearance
Correct answers: a, d, e Rationale: The appearance of partial-thickness (deep) burns may include fluid-filled vesicles (blisters) that are red, shiny, or wet (if vesicles have ruptured). Patients may have severe pain caused by exposure of nerve endings and may have mild to moderate edema.
27. An emergency department nurse has just received a burn victim brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the patient's body. The nurse knows that pathophysiologic changes resulting from major burns during the initial burn-shock period include what? A) Hyper-dynamic anabolism B) Hyper-metabolic catabolism C) Decreased cardiac output D) Organ hyper-function
DECREASED CARDIAC OUTPUT **Pathophysiologic changes resulting from major burns during the initial burn-shock period include tissue hypo-perfusion and organ hypo-function secondary to decreased cardiac output, followed by a hyper-dynamic and hyper-metabolic phase. Options A and B are distracters for this question.
31. The acute phase of the burn begins 48 to 72 hours after the burn. What begins at this time? A) Cardiac output decreases B) Renal failure begins C) Diuresis D) Fluid moves from intravascular compartment to interstitial spaces
DIURESIS **As capillaries regain integrity, 48 or more hours after the burn, fluid moves from the interstitial to the intravascular compartment and diuresis begins. Cardiac output should increase and renal output should increase.
8. A patient has sustained a severe burn injury and is thought to have an impaired intestinal mucosal barrier. Since this patient is considered at an increased risk for infection, what intervention will assist in avoiding increased intestinal permeability and prevent early endotoxin translocation? A) Early enteral feeding B) Administration of prophylactic antibiotics C) Bowel cleansing procedures D) Administration of stool softeners
EARLY AND ENTERAL FEEDING **If the intestinal mucosa receives some type of protection against permeability change, infection could be avoided. Early enteral feeding is one step to help avoid this increased intestinal permeability and prevent early endotoxin translocation. Antibiotics are seldom prescribed prophylactically because of the risk of promoting resistant strains of bacteria. A bowel cleansing procedure would not be ordered for this patient. The administration of stool softeners would not assist in avoiding increased intestinal permeability and prevent early endotoxin translocation.
9. A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. What would be the nurse's priority concern about this patient? A) Fluid status B) Risk of infection C) Body image D) Level of pain
FLUID STATUS **During the early phase of burn care, the nurse is most concerned with fluid resuscitation, to correct large-volume fluid loss through the damaged skin. Infection, body image, and pain are significant areas of concern, but are less urgent than fluid status.
A patient is brought to the Emergency Department from the site of a chemical fire. The paramedics report that the patient has a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. When you assess the patient he verbalizes no pain in the right arm and the skin appears charred. Based upon these assessment findings, what is the depth of the burn on the patient's right arm? A) Superficial partial-thickness B) Deep partial-thickness C) Full partial-thickness D) Full-thickness
FULL THICKNESS **A full-thickness burn involves total destruction of the epidermis and dermis and, in some cases, underlying tissue as well. Wound color ranges widely from white to red, brown, or black. The burned area is painless because the nerve fibers are destroyed. The wound can appear leathery; hair follicles and sweat glands are destroyed. Edema may also be present. Full partial thickness is not a depth of burn. Superficial partial-thickness burns involve the epidermis and possibly a portion of the dermis and the patient will experience pain that is soothed by cooling. Deep partial-thickness burns involve the epidermis, upper dermis, and portion of the deeper dermis and the patient will complain of pain and sensitivity to cold air.
25. A burn patient is brought to the emergency department. The nurse knows that the first systemic event after a major burn injury is what? A) Hemodynamic instability B) Metabolic acidosis C) Hypovolemia D) Hyperkalcemia
HEMODYNAMIC INSTABILITY **The initial systemic event after a major burn injury is hemodynamic instability, which results from loss of capillary integrity and a subsequent shift of fluid, sodium, and protein from the intravascular space into the interstitial spaces. Options B, C, and D occur, they are just not the first event to happen.
A patient in the emergent/resuscitative phase of a burn injury has had her lab work drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what? A) Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis B) Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis C) Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis D) Hypokalemia, hyponatremia, elevated hematrocrit, and metabolic alkalosis
HYPERKALEMIA, HYPONATREMIA, ELEVATED HEMATOCRIT AND METABOLIC ACIDOSIS **Fluid and electrolyte changes in the emergent/resuscitative phase of a burn injury include hyperkalemia related to the release of potassium into the extracellular fluid, hyponatremia from large amount of sodium lost in trapped edema fluid, hemoconcentration that leads to an increased hematocrit, and loss of bicarbonate ions that results in metabolic acidosis.
A nurse on the burn unit is caring for a patient who has gone into the acute phase of her burn. What would be important for the nurse to monitor the patient for? A) Hypometabolism B) Hyponatremia C) Hyperkalemia D) Hypoglycemia
HYPONATREMIA **Hyponatremia is common during the first week of the acute phase, as water shifts from the interstitial space to the vascular space. Hypermetabolism can occur up to 1 year after the burn. Hyperkalemia occurs in the emergent phase of the burn. In a burn patient there is a hyperglycemic response, not a hypoglycemic response.
29. A patient is admitted to the burn unit after being transported from a facility 1000 miles away. The patient has burns to the groin area and both legs. The burns to the lower legs are circumferential. The nurse knows to monitor closely for what as the edema in this patient increases? A) Ischemia B) Eschar C) Hyper-profusion to the burned area D) Increased fluid loss through the burned area
ISCHEMIA **As edema increases, pressure on small blood vessels and nerves in the distal extremities causes an obstruction of blood flow and consequent ischemia. This complication is similar to compartment syndrome. The physician may need to perform an escharotomy, a surgical incision into the eschar (devitalized tissue resulting from a burn), to relieve the constricting effect of the burned tissue.
38. What is a priority in the rehabilitation phase of the burn injury? A) Monitoring fluid and electrolyte imbalances B) Patient and family education C) Assessing wound healing D) Documenting family support
PATIENT AND FAMILY EDUCATION **Patient and family education is a priority in the acute and rehabilitation phases. There should be no fluid and electrolyte imbalances in the rehabilitation phase. Assessing wound healing is an ongoing function but it is not a priority in the rehabilitation phase. Documenting family support is not a priority in the rehabilitation phase.
36. You are caring for a burn patient who is in the later stages of the acute phase of the burn injury. What is an important factor in your care of the patient? A) Immobilizing the patient B) Maintaining splints and functional devices C) Maintaining ongoing discussion about the patient with a psychologist D) Prevention of DVT
PREVENTION OF DVT **Prevention of deep vein thrombosis (DVT) is an important factor in care. Early mobilization of the patient is important. The nurse monitors the splints and functional devices, but does not maintain them. The nurse does not maintain discussion with a psychologist about the patient.
18. The nursing instructor is teaching about the emergent/resuscitative phase of burn injury. During this phase, what would the nursing instructor tell the students they should closely monitor in the laboratory values? A) Sodium deficit B) Bleeding time C) Potassium deficit D) Decreased hematocrit
SODIUM DEFICIT **Anticipated fluid and electrolyte changes that occur during the emergent/resuscitative phase of burn injury include potassium excess, sodium deficit, base-bicarbonate deficit, and elevated hematocrit.
35. It is time to change the dressings on a burn patient. What does the nurse do to reduce pain and discomfort at this time? A) The nurse lets the patient decide on when to change the dressing. B) The nurse skip's the dressing change if the patient is really uncomfortable. C) The nurse changes dressings as quickly as possible. D) The nurse lets the aide do the painful part of the dressing change.
THE NURSE CHANGES DRESSINGS AS QUICKLY AS POSSIBLE **The nurse works quickly to complete treatments and dressing changes to reduce pain and discomfort. Letting the patient decide the time of the dressing change lets the patient feel more in control. It doesn't reduce pain and discomfort. The nurse should never skip an ordered dressing change. You never delegate a dressing change on a burn patient.
33. What is the nursing goal during the acute phase of a burn? A) To ultimately prevent or control infection in the burn population B) To prevent hypervolemia in the burn population C) To manage pain in a proactive way for the patient's comfort D) To provide emotional support as the changes in body image become internalized in the patient
TO ULTIMATELY PREVENT OR CONTROL INFECTION IN THE BURN POPULAITON **The nursing goal is to provide protection and safety in the patients' environment to ultimately prevent or control infection in the burn population. This makes options B, C, and D incorrect.
The occupational health nurse is called to the floor of the factory where a patient has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to "cool the burn." How will the nurse cool the burn? A) Apply ice to the site of the burn for 5 to 10 minutes. B) Wrap the patient's affected extremity in ice until help arrives. C) Apply an oil-based substance or butter to the burned area until help arrives. D) Wrap cool towels around the affected extremity intermittently.
WRAP COOL TOWELS AROUND AFFECTED EXTREMITY INTERMITTANTLY **Once the burn has been sustained, the application of cool water is the best first-aid measure. Soaking the burn area intermittently in cool water or applying cool towels gives immediate and striking relief from pain and limits local tissue edema and damage. However, 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 admitted to the emergency department with first- and second-degree burns after being involved in a house fire. Which assessment findings would alert you to the presence of an inhalation injury? (select all that apply)? a. singed nasal hair b. generalized pallor c. painful swallowing d. burns on the upper extremities e. history of being involved in a large fire
a, b, c, e Reliable clues to the occurrence of inhalation injury is the presence of facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral and nasal membranes, carbonaceous sputum, history of being burned in an enclosed space, altered mental status, and "cherry red" skin color.
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)? a. escharotomy b. administration of diuretics c. IV and oral pain medications d. daily cleansing and debridement e. application of topical antimicrobial agent
a, c, d, e An escharotomy (a scalpel incision through full-thickness eschar) is frequently required to restore circulation to compromised extremities. Daily cleansing and debridement as well as application of an antimicrobial ointment are expected interventions used to minimize infection and enhance wound healing. Pain control is essential in the care of a patient with a burn injury. With full-thickness burns, myoglobin and hemoglobin released into the bloodstream can occlude renal tubules. Adequate fluid replacement is used to prevent this occlusion.
During the care of the patient with a burn in the acute phase, which new interventions should the nurse expect to do after the patient progressed from the emergent phase? a. begin IV fluid replacement b. monitor for signs of complications c. access and manage pain and anxiety d. discuss possible reconstructive surgery
b Monitoring for complications (e.g., wound infection, pneumonia, contractures) is needed in the acute phase. Fluid replacement occurs in the emergent phase. Assessing and managing pain and anxiety occurs in the emergent and the acute phases. Discussing possible reconstructive surgeries is done in the rehabilitation phase
A nurse is caring for a patient with second- and third-degree burns to 50% of the body. The nurse prepares fluid resuscitation based on knowledge of the Parkland (Baxter) formula that includes which recommendation? a. The total 24-hour fluid requirement should be administered in the first 8 hours. b. One half of the total 24-hour fluid requirement should be administered in the first 8 hours. c. One third of the total 24-hour fluid requirement should be administered in the first 4 hours. d. One half of the total 24-hour fluid requirement should be administered in the first 4 hours.
b. Fluid resuscitation with the Parkland (Baxter) formula recommends that one half of the total fluid requirement should be administered in the first 8 hours, one quarter of total fluid requirement should be administered in the second 8 hours, and one quarter of total fluid requirement should be administered in the third 8 hours.
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? a. SQ tetanus toxoid b. IV morphine sulfate c. IM hydromorphone d. PO oxycodone and acetaminophen
b. IV medications are used for burn injuries in the emergent phase to rapidly deliver relief and prevent unpredictable absorption as would occur with the IM route. The PO route is not used because GI function is slowed or impaired due to shock or paralytic ileus, although oxycodone and acetaminophen may be used later in the patient's recovery. Tetanus toxoid may be administered but not for pain.
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? a. blisters b. reddening of the skin c. destruction of all skin layers d. damage to sebaceous glands
b. 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
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? a. 18% b. 22.5% c. 27% d. 36%
b. 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. Since 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.
When caring for a patient with an electrical burn injury, which order from the health care provider should the nurse question? a. mannitol 75 gm IV b. urine for myoglobulin c. LR at 25 mL/h d. sodium bicarbonate 24 mEq q.4h
c. An infusion rate of 25 mL/hr is not sufficient to maintain adequate urine output in prevention and treatment of ATN. 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 2-4 mL/kg/%TBSA, a rate sufficient to maintain urinary output at 75 to 100 mL/hr. Mannitol can also be used to maintain urine output. Sodium bicarbonate may be given to alkalinize the urine. The urine would also be monitored for the presence of myoglobin.
The patient received a cultured epithelial autograft (CEA) to the entire left leg. What should the nurse include in the discharge teaching for this patient? a. sit or lay in the position of comfort b. wear a pressure garment for 8 hours each day c. refer the patient to a counselor for phychosocial support d. use the sun to increase the skin color on the healed areas
c. 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 they 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.
The patient in the acute phase of burn care has electrical burns on the left side of her 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? a. replace the blood lost b. maintain a neutral pH c. maintain fluid balance d. replace serum potassium
c. This patient is most likely experiencing hyperosmolar hyperglycemic syndrome (HHS). HHS dehydrates a patient rapidly. Thus HHS combined with the massive fluid losses of a burn tremendously increase this patient's risk for hypovolemic shock and serious hypotension. This is clearly the nurse's priority because the nurse must keep up with the patient's fluid requirements to prevent circulatory collapse caused by low intravascular volume. There is no mention of blood loss. Fluid resuscitation will help to correct the pH and serum potassium abnormalities.
The nurse is caring for a patient with partial- and full-thickness burns to 65% of the body. When planning nutritional interventions for this patient, what dietary choices should the nurse implement? a. full liquids only b. whatever the patient requests c. high-protein and low sodium foods d. high calorie and high protein foods
d. A hypermetabolic state occurs proportional to the size of the burn area. Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. Caloric needs are often in the 5000-kcal range. Failure to supply adequate calories and protein leads to malnutrition and delayed healing.
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? a. Serum sodium and potassium increase b. Serum sodium and potassium decrease. c. Edema and arterial blood gases improve. d. Diuresis occurs and hematocrit decreases.
d. 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 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.
The ambulance reports that they are transporting a patient to the ED who has experienced a full-thickness thermal burn from a grill. What manifestations should the nurse expect? a. severe pain, blisters, and blanching with pressure b. pain, minimal edema, and blanching with pressure c. redness, evidence of inhalation injury, and charred skin d. no pain, waxy white skin, and no blanching with pressure
d. 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.
