Chapter 24: Burns

An employee spills industrial acid on both arms and legs at work. What action should the occupational health nurse take? 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.

ANS: A With chemical burns, the first action is to remove the chemical from contact with the skin as quickly as possible.

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 for breath sounds. b. determine the extent and depth of the burns. c. give the prescribed hydromorphone. d. infuse the prescribed lactated Ringer's solution.

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

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 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.

ANS: A Sterile gloves should be worn when applying medications or dressings to a burn.

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 b. peripheral pulses c. extremity movement d. pupil reaction to light

ANS: C All patients with electrical burns should be considered at risk for cervical spine injury, and assessment of extremity movement will provide baseline data.

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. b. place on heart monitor. c. check potassium level. d. assess oral temperature.

ANS: B After an electrical burn, the patient is at risk for life-threatening dysrhythmias and should be placed on a heart monitor.

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 nutrition. c. infuse total parenteral nutrition via a central catheter. d. encourage an oral intake of at least 5000 kcal per day.

ANS: B Enteral nutrition can usually be started during the emergent phase at low rates and increased over 24 to 48 hours to the goal rate.

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.

ANS: B The decrease in pulse and numbness in a patient with circumferential burns shows decreased circulation to the legs and the need for an escharotomy.

A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased, and no wheezes are audible. What action should the nurse take? a. encourage the patient to cough and auscultate the lungs again. b. notify the health care provider and prepare for endotracheal intubation. c. document the results and continue to monitor the patient's respiratory rate. d. reposition the patient in high-Fowler's position and reassess breath sounds.

ANS: B The patient's history and clinical manifestations suggest airway edema, and the health care provider should be notified at once so that intubation can be done rapidly.

A patient admitted with burns over 30% of the body surface 2 days ago now has dramatically increased urine output. Which action should the nurse plan to support maintaining kidney function? a. monitoring white blood cells (WBCs). b. continuing to measure the urine output. c. assessing that blisters and edema have subsided. d. encouraging the patient to eat adequate calories.

ANS: B The patient's urine output indicates that the patient is entering the acute phase of the burn injury and moving on from the emergent stage. At the end of the emergent phase, capillary permeability normalizes, and the patient begins to diurese large amounts of urine with a low specific gravity.

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.

ANS: B The right hand and arm should be elevated to reduce swelling and the fingers extended to avoid flexion contractures (even though this position may not be comfortable for the patient).

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. 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.

ANS: B The urine output should be at least 0.5 to 1.0 mL/kg/hr during the emergent phase, when the patient is at great risk for hypovolemic shock.

Which patient should the nurse assess first? a. a patient with burns who reports a 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.

ANS: B This patient has evidence of lower airway injury and hypoxemia and should be assessed at once to determine the need for O2 or intubation (or both).

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 should the nurse make? 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."

ANS: B This response acknowledges the patient's feelings and asks for more assessment data that will help in developing an appropriate plan of care to assist the patient with the emotional response to the burn injury.

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

ANS: B With full-thickness skin destruction, the appearance is pale and dry or leathery, and the area is painless because of the associated nerve destruction.

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 a twice-daily burn debridement to partial-thickness facial burns. b. a patient who just returned from having a cultured epithelial autograft to the chest. c. a patient who has a 15% weight loss from admission and will need enteral feedings. d. a patient who has blebs under an autograft on the thigh and has an order for bleb aspiration.

ANS: C An RN from a medical unit would be familiar with malnutrition and with administration and evaluation of response to enteral feedings.

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 b. orange gelatin c. vanilla milkshake d. whole grain bagel

ANS: C A patient with a burn injury needs high-protein and high-calorie food intake, and the milkshake is the highest in these nutrients.

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. b. check the blood pressure. c. stabilize the cervical spine. d. assess alertness and orientation.

ANS: C Cervical spine injuries are often associated with electrical burns. Therefore, stabilization of the cervical spine takes precedence after airway management.

Esomeprazole 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 b. stool frequency c. stool occult blood d. abdominal distention

ANS: C H2 blockers and proton pump inhibitors are given to prevent Curling's ulcer in the patient who has sustained burn injuries.

A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be given in the first 24 hours is 30,000mL. The initial rate of administration is 1875mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids? a. 219mL/hr b. 625mL/hr c. 938mL/hr d. 1875mL/hr

ANS: C Half of the fluid replacement using the Parkland formula is administered in the first 8 hours and the other half over the next 16 hours.

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% b. serum sodium of 147 c. serum potassium of 6.1 d. blood urea nitrogen of 37

ANS: C Hyperkalemia can lead to life-threatening dysrhythmias. The patient needs cardiac monitoring and immediate treatment to lower the potassium level.

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. place the patient on 100% O2 using a nonrebreather mask. d. assess for singed nasal hair and dark oral mucous membranes.

ANS: C The patient's history and skin color suggest carbon monoxide poisoning, which should be treated by rapidly starting O2 at 100%.

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, serum potassium 4.9, and serum sodium 135. 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

ANS: C The patient's laboratory results show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased.

A young adult patient who is in the rehabilitation phase after having deep partial-thickness face and neck burns has been having difficulty with body image over the past several months. 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."

ANS: C The willingness to use strategies to enhance appearance is an indication that the disturbed body image is resolving.

Which nursing action prevents cross contamination when the patient's full-thickness burn wounds to the face are exposed? a. using sterile gloves when removing dressings. b. keeping the room temperature at 70° F (20° C). c. wearing gown, cap, mask, and gloves during care. d. giving IV antibiotics to prevent bacterial colonization.

ANS: C Use of gowns, caps, masks, and gloves during all patient care will decrease the possibility of wound contamination for a patient whose burns are not covered.

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.

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

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.

ANS: D Application of water-based emollients will moisturize new skin and decrease flakiness and itching.

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

ANS: D Opioid pain medications are the best choice for pain control.

During the emergent phase of burn care, which assessment is most useful in determining whether the patient is receiving adequate fluid infusion? a. check skin turgor. b. monitor daily weight. c. assess mucous membranes. d. measure hourly urine output.

ANS: D When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hr.

In which order will the nurse take these actions when doing a dressing change for a partial-thickness burn wound on a patient's chest? a. Apply sterile gauze dressing. b. Document wound appearance. c. Apply silver sulfadiazine cream. d. Give IV fentanyl (Sublimaze). e. Clean wound with saline-soaked gauze.

ANS: D, E, C, A, B Because partial-thickness burns are very painful, the nurse's first action should be to give pain medications. The wound will then be cleaned, antibacterial cream applied, and covered with a new sterile dressing. The last action should be to document the appearance of the wound.