EAQ Burns

A nurse is attending to a patient with partial-thickness burns on the hands and legs. What actions should the nurse perform as a part of the wound care for the emergent phase of treatment? Select all that apply. 1. Administer a tetanus antitoxin. 2. Avoid using topical antibiotics. 3. Avoid using antimicrobial dressings. 4. Assess the extent and depth of the burns. 5. Perform debridement as required.

1. Administer a tetanus antitoxin. 4. Assess the extent and depth of the burns. 5. Perform debridement as required. The burn management involves emergent phase, acute phase, and rehabilitation phase. The emergent phase involves early management of the burns patient and includes airway management, and fluid and wound therapy. Tetanus antitoxin should be administered to prevent sepsis. Assessment of extent and depth of burns should be done to determine the severity of burns, plan burns management, and consider referring to a burn center. Debridement should be performed as required to keep the wound clean, remove any chemical causing the burn, or to prevent further tissue damage. Use of topical antibiotics and antimicrobial dressings are not of prime importance in the emergent phase; they are usually used in the acute and rehabilitation phases.

A nurse is attending to a patient with extensive burns. What prophylactic treatment should the nurse plan to prevent a Curling's ulcer in this patient? Select all that apply. 1. Antacids 2. Antidiarrheal 3. H2-histamine blockers 4. Proton pump inhibitors 5. Calcium channel blockers

1. Antacids 3. H2-histamine blockers 4. Proton pump inhibitors Antacids are used prophylactically to neutralize the acids present in the stomach. H2-histamine blockers (e.g. ranitidine [Zantac]) are used to inhibit histamine, which causes increase in acid levels. Proton pump inhibitors (e.g. esomeprazole [Nexium]) help to inhibit the secretion of hydrochloric acid, which increases as a stress response to the decreased blood flow to the gastrointestinal tract after burns. Antidiarrheal is useful in providing symptomatic relief for diarrhea. It cannot prevent a Curling's ulcer. Calcium channel blockers have no effect on protecting the gastrointestinal tract or on preventing development of Curling's ulcers.

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

1. Ask caregivers to get the patient's favorite food. 3. Suggest a high-protein diet 5. Suggest a high-carb diet The patient may have a reduced appetite and may not like the food from the hospital. Therefore, the caregivers can get the patient's favorite food. A swallowing assessment should be done by a speech pathologist before beginning with oral feeds. The patient should be provided with a high-protein diet to promote tissue healing and avoid malnutrition. A high-carbohydrate diet should be provided to meet the high metabolic demands. A low-calorie food may not meet the calorie requirements of the patient and leads to malnutrition and delayed wound healing. An adequate intake of fluids is essential for healing.

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. Begin fluid replacement. 3. Cover burned areas with dry dressings. 5. Establish IV access with two large-bore catheters. Begin fluid replacement to compensate for fluid loss. Cover the burned areas with dry dressings to begin the healing process and thus prevent contamination. An intravenous access should be established with two large-bore catheters to enable large amounts of fluid replacements. Supplemental oxygen is required to maintain adequate perfusion. The injured limb should be kept elevated above the heart level to prevent and decrease swelling

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

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

A patient is admitted to the burn unit with second-degree thermal burns. Which characteristics of a second-degree thermal burn should the nurse expect to find during the physical assessment? Select all that apply. 1. Fluid-filled vesicles 2. Severe pain 3. Mild edema 4. Waxy, white, hard skin 5. Visible thrombosed vessels Second-degree burns show epidermal and dermal involvement to varying depths. These burn injuries are characterized by fluid-filled vesicles that are erythematous, glossy, and damp. The patient may complain of severe pain caused by nerve injury. Mild to moderate edema may be present. Waxy, white, hard skin and visible thrombosed vessels are found in third-degree burns.

1. Fluid-filled vesicles 2. Severe pain 3. Mild edema Second-degree burns show epidermal and dermal involvement to varying depths. These burn injuries are characterized by fluid-filled vesicles that are erythematous, glossy, and damp. The patient may complain of severe pain caused by nerve injury. Mild to moderate edema may be present. Waxy, white, hard skin and visible thrombosed vessels are found in third-degree burns.

A nurse is teaching a patient's caregivers about the immediate action to be taken in case of burns of more than 10% of body surface area. What reasons does the nurse provide for avoiding the use of ice on the burned body part? Select all that apply. 1. Ice can cause hypothermia. 2. Ice can stop further tissue damage. 3. Ice can cause vasoconstriction. 4. Ice can reduce blood flow to the burned area. 5. Ice can increase the blood flow to the burned area.

1. Ice can cause hypothermia. 3. Ice can cause vasoconstriction. 4. Ice can reduce blood flow to the burned area. Ice can cause hypothermia, resulting in excessive cooling of the burned part and reduction of blood flow to that area. Ice can also cause vasoconstriction, thus causing the blood vessels supplying the burned area to narrow and supply less blood and oxygen. Applying ice does not prevent further tissue damage; instead, it decreases the blood supply, causing delayed wound healing. Ice does not increase the blood flow to the burned area; rather it decreases the blood flow due to vasoconstriction.

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

1. Increasing hoarseness 4. Darkened oral or nasal membranes 5. Productive cough with black sputum In inhalation burns, either the respiratory tract is exposed to intense fumes or heat, or the patient inhales noxious chemicals or smoke. Increasing hoarseness is seen due to irritation of the upper airway during inhalation and the laryngeal edema caused by inhalation injury. Some other signs include darkened oral or nasal membranes and productive cough with black sputum, which are evident due to charring of the membranes of the respiratory tract. Location of contact points is done in case of electrical burns. In this case, the skin may appear leathery white and charred.

A patient is being treated for burns on the face and ears due to a fire at home. What precautions should the nurse take to protect the ears from damage? Select all that apply. 1. Keep ears free from pressure. 2. Avoid using pillows. 3. Apply a heavy gauze dressing for fast healing. 4. Wrap ears with sterile gauze after applying ointment. 5. Elevate patient's head by placing rolled towel under shoulders.

1. Keep ears free from pressure. 2. Avoid using pillows. 5. Elevate patient's head by placing rolled towel under shoulders. Ears should be kept free from pressure because of their poor vascularization and tendency to become infected. Avoid using pillows, as the pressure on ear cartilage may cause chondritis, and the ear may adhere to the pillowcase, causing pain and bleeding. The patient's head is elevated by placing a rolled towel under shoulders to reduce pressure over the ears. It helps to prevent pressure necrosis. A heavy gauze dressing should not be applied, as it can put pressure on the ears and damage them. Ears are not to be wrapped with sterile gauze after applying ointment in order to avoid pressure over the ears.

The nurse recalls which description as the most accurate regarding a deep partial-thickness burn? 1. Painful with weeping blisters 2. Minimal damage to the epidermis 3. Charring visible in the deepest areas 4. Necrotic tissue through all layers of the skin

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

When planning for burn management, which patients should the nurse refer to a burn center? Select all that apply. 1. Patients with hydrochloric acid burns 2. Patients of all ages with first-degree burns 3. Patients of all ages with third-degree burns 4. Patients with 25% deep partial-thickness burns 5. Patients with 5% superficial partial-thickness burns

1. Patients with hydrochloric acid burns 3. Patients of all ages with third-degree burns 4. Patients with 25% deep partial-thickness burns Patients suffering from hydrochloric acid burns, also known as chemical burns, should be referred to a burn center. Patients of all ages with third-degree burns are severe in condition and should be treated in a burn center. All patients with partial-thickness burns more than 10% should be referred to a burn center, as they are severe types of burns and need specialized treatment, care, and isolation. Patients of all ages with first-degree burns can be managed in the hospital and assessed. Patients with 5% superficial partial-thickness burns need not necessarily be referred and can be managed in the hospital.

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

1. Restlessness 3. Increased agitation 5. Increased rate of breathing Restlessness can result from respiratory distress, as the patient experiences disturbances in breathing. Increased agitation could result from the patient's attempts to compensate for an increasing oxygen demand and can be a sign of respiratory distress. An increased respiratory rate is a compensatory mechanism for the increased oxygen demands. It is a sign of impending respiratory distress and needs immediate attention. Increased sleep does not result from respiratory distress, as the patient becomes restless. Increased water intake is not specific to respiratory distress.

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

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

A patient with partial-thickness burns is being treated with zolpidem (Ambien). What is the appropriate nursing response to the patient's caregivers when they ask about the purpose of administering this drug? Select all that apply. 1. To promote sleep 2. To reduce anxiety 3. To promote wound healing 4. To prevent thromboembolism 5. To provide short-term amnesic effects

1. To promote sleep 2. To reduce anxiety 5. To provide short-term amnesic effects Zolpidem is a sedative-hypnotic medicine and is given to patients suffering from burns. Zolpidem promotes sleep, reduces anxiety, and provides short-term amnesic effects. Nutritional support is used to promote wound healing. Anticoagulants are used to prevent thromboembolism

A patient is brought to the emergency department (ED) with severe burns on the legs and feet. Which factors lead the nurse to believe the patient may have full-thickness burns? Select all that apply. 1. Touch sensation is impaired. 2. Blanching with pressure is observed. 3. Lack of blanching with pressure is observed. 4. Wounds appear mottled white, pink to cherry-red. 5. Wounds appear waxy white, dark brown, or charred.

1. Touch sensation is impaired. 3. Lack of blanching with pressure is observed. 5. Wounds appear waxy white, dark brown, or charred. Touch sensation is impaired due to impaired nerve endings in full-thickness burns. Lack of blanching with pressure is observed, as all skin elements are destroyed. Wounds appear waxy white, dark brown, or charred in full-thickness burns, as all skin elements and local nerve endings are destroyed, and coagulation necrosis is present. Blanching with pressure is observed in partial-thickness burns because varying degrees of both the epidermis and dermis are involved, and skin elements of regeneration are viable. Wounds appear mottled white, pink to cherry-red in a partial-thickness burn.

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. Arrange for ophthalmology examination. 4. Instill methylcellulose eye drops. 5. Inform the patient that periorbital edema is serious.

1. Use antibiotic ointments. 3. Arrange for ophthalmology examination. 4. Instill methylcellulose eye drops. Eye care for corneal burns or edema includes antibiotic ointments. An ophthalmology examination should be conducted on all patients who have sustained facial burns. The use of methylcellulose drops or artificial tears is recommended for moisture and additional comfort. Waiting for laboratory reports does not help the patient; rather, the nurse can start the basic examination and treatment in the process mentioned above. Avoid giving any misleading information, such as telling the patient that periorbital edema is serious. This can frighten the patient and prevent eye opening. The nurse should assure the patient that the swelling is not permanent.

A patient has 20% total body surface area (TBSA) burns from a brush fire. For the past week, the patient's wounds have been debrided and covered with a silver-impregnated dressing. Today the nurse noticed that the partial-thickness burn wounds have been fully debrided. The nurse's priority intervention for wound care at this time would be to 1. Reapply a new dressing without disturbing the wound bed 2. Apply fine-meshed petroleum gauze to the debrided areas 3. Wash the wound aggressively with sterile saline three times a day 4. Apply cool compresses for pain relief in between dressing changes

2. Apply fine-meshed petroleum gauze to the debrided areas When the partial-thickness burn wounds have been fully debrided, a protective, coarse or fine-meshed, greasy-based (paraffin or petroleum) gauze dressing is applied to protect the re-epithelializing keratinocytes as they resurface and close the open wound bed. The nurse would not wash the wound aggressively with saline three times daily, apply cool compresses, or apply a new dressing at this time.

Which type of burn injury occurs on the layers of subcutaneous fat, muscle, or deeper structures? 1. Sunburn 2. Full thickness burn 3. Deep partial thickness burn 4. Superficial partial thickness burn

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

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

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

The nurse is attending to a patient who is recovering from a full-thickness burn. The nurse understands that the patient is in a hypermetabolic state and needs nutritional support to promote wound healing and prevent malnutrition. What types of food and drinks should the nurse provide to the patient? Select all that apply. 1. Tea 2. Milkshakes 3. Protein powder 4. Low-protein food 5. High-calorie food

2. Milkshakes 3. Protein powder 5. High-calorie food A patient with burns needs a high-calorie diet to compensate for the energy loss and increased protein intake to avoid malnutrition and delayed healing. Milkshakes have high calories. Protein powder provides high protein. High-caloric food contains calories in large quantities and will help in the patient's recovery. Tea does not provide adequate quantities of calories and proteins. Low-protein food is not advised for a patient with burns, as the demand for proteins is high to promote healing and a faster recovery.

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. 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.

2. One half of the total 24-hour fluid requirement should be administered in the first 8 hours. 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 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? 1. Blisters 2. Reddening of the skin 3 .Destruction of all skin layers 4. Damage to sebaceous glands

2. Reddening of the skin 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 with a burn inhalation injury is receiving albuterol (Ventolin) for bronchospasm. What is the most important adverse effect of this medication for the nurse to manage? 1. Gastrointestinal (GI) distress 2. Tachycardia 3. Restlessness 4. Hypokalemia

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

Which precautions should the nurse take when changing a burn wound dressing? Select all that apply. 1. Use sterile gloves when removing a contaminated dressing. 2. Use sterile gloves when applying ointments and sterile dressings. 3. Keep the room cool to decrease the burning sensation of the wound. 4. Wear non-sterile, disposable gloves when washing the dirty wound. 5. Always wear personal protective equipment, such as masks, gowns, and gloves.

2. Use sterile gloves when applying ointments and sterile dressings. 4. Wear non-sterile, disposable gloves when washing the dirty wound. 5. Always wear personal protective equipment, such as masks, gowns, and gloves. The nurse should use sterile gloves when applying ointment and sterile dressings. Nonsterile, disposable gloves should be worn when removing contaminated dressings and washing a dirty wound. The nurse should always wear personal protective equipment before the burn wounds are exposed. The room should be kept warm to prevent shivering in the patient.

A patient is admitted to the burns ward with deep partial-thickness burns on the hands. What characteristics is the nurse likely to find when performing examination of the wound? Select all that apply. 1. Wounds are painless. 2. Wounds are wet and shiny. 3. Wounds are painful to touch. 4. Wounds appear pink to cherry-red. 5. Wounds appear black and leathery.

2. Wounds are wet and shiny. 3. Wounds are painful to touch. 4. Wounds appear pink to cherry-red. Partial-thickness wounds are wet and shiny due to serous exudates. These wounds are painful to touch due to nerve injury. Wounds appear pink to cherry-red. Wounds are painless in full-thickness burns due to nerve destruction. Wounds appear black and leathery in full-thickness burns, as all skin elements and local nerve endings are destroyed, and coagulation necrosis is present

A patient sustains burns covering 35% of the body surface area. The patient weighs 100 kg. Which action is most appropriate for the nurse to take during the early course of the patient's care? 1. Administering 3500 mL of colloid IV fluids over the 8 hours after injury 2. Administering 140 mL/hr of colloid IV fluids for the 24 hours after injury 3. Administering 7000 mL of crystalloid IV fluids over the 8 hours after injury 4. Administering 14,000 mL of crystalloid IV fluids over the 12 hours after injury

3. Administering 7000 mL of crystalloid IV fluids over the 8 hours after injury Crystalloid solutions, such as Ringer's lactate, are indicated for use in the initial IV fluid therapy for a burn patient. IV fluids for the first 24 hours may be calculated with the use of the Parkland formula based on body surface area (BSA), 4 mL/kg × BSA; therefore (4 mL × 100 kg) × 35 = 14,000 mL. The Parkland formula calls for half of the total fluids to be given over the first 8 hours, with the remaining given over the next 16 hours. Therefore the IV fluid prescription would be 7000 mL over 8 hours and 7000 mL over the next 16 hours.

A patient has thermal burns on his face, including the cheeks and the area around the eyes. Which measures should the nurse take? 1. Instill artificial tears in each eye. 2. Wrap sterile gauze around his face. 3. Cover his face with silver sulfadiazine ointment and gauze. 4. Apply silver sulfadiazine ointment only without the use of gauze.

3. Cover his face with silver sulfadiazine ointment and gauze. The face is highly vascular and may become edematous after a thermal burn. It should be covered with ointment and gauze to prevent vascularization and swelling. Wrapping gauze around the face will create pressure on delicate facial structures. The gauze is required to cover the face after the application of silver sulfadiazine ointments to prevent infection. Artificial tears or methylcellulose drops are used to treat eyes after a burn.

When teaching patients and caregivers about the strategies to reduce burn injuries, what essential instructions does the nurse give? Select all that apply. 1. Store chemicals in the lowest shelves to avoid mixing up with other household chemicals. 2. Perform outdoor activities during lightning storms. 3. Ensure an electrical power source is shut off before beginning repairs. 4. Never leave burning candles unattended or near windows or curtains. 5. Check temperature of bath water with the back of hand or bath thermometer.

3. Ensure an electrical power source is shut off before beginning repairs. 4. Never leave burning candles unattended or near windows or curtains. 5. Check temperature of bath water with the back of hand or bath thermometer. Ensure that the electrical power source is shut off before beginning any repairs to avoid electrical burn injury. Never leave candles unattended or near open windows or curtains to avoid fire. Check the temperature of the bath water using the back of the hand or use the bath thermometer to avoid scalding burns, which commonly occur due to hot bathing water. Chemicals should be stored safely, preferably out of reach of children, in clearly written labels. Performing outdoor activities during lightning storms increases the risk of electrical injury from the ongoing lightning.

A patient is brought to the emergency department (ED) following an inhalation injury. The patient has sustained burns on the face, neck, and chest due to a fire in the home. Which would help to confirm the diagnosis of upper airway injury? Select all that apply. 1. Dyspnea 2. Wheezing 3. Hoarseness 4. Singed nasal hair 5. Difficulty in swallowing

3. Hoarseness 4. Singed nasal hair 5. Difficulty in swallowing Upper airway injury may be caused by thermal burns or the inhalation of hot air, steam, or smoke. Hoarseness occurs due to laryngeal edema. Singed nasal hair is an obvious sign of inhalation of burned particles or smoke. Difficulty in swallowing is present due to edema and blistering of the oropharynx. Dyspnea can be observed where there has been an inhalation injury to the lower airway that is caused by breathing toxic chemicals or smoke that affects the trachea, bronchioles, and alveoli. Wheezing is a symptom found in an inhalation injury affecting the lower airway.

An 82-year-old patient is moving into an independent living facility. What is the best advice the nurse can give to the family to help prevent this patient from being accidently burned in the new home? 1. Cook for the patient 2. Stop the patient from smoking 3. Install tap water anti-scald devices 4. Be sure the patient uses an open space heater

3. Install tap water anti-scald devices

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

3. Monitor for signs of complications. 4. Continue assessing oxygenation needs. 5 .Continue to monitor respiratory status. The nurse should monitor for signs of respiratory complications of burns to plan for appropriate respiratory therapy. Continue assessing oxygenation needs to plan for any alternations in oxygen supply. Continue to monitor the respiratory status to ensure proper breathing and circulation. Avoiding supplemental oxygen is not advisable, as oxygen needs may be assessed and started as required. Preparing for discharging the patient needs to be planned in the rehabilitation phase after the patient has recovered.

While planning physical therapy for a patient suffering from burns, which should be included? Select all that apply. 1. Practice physical therapy only occasionally. 2. Perform exercises before wound cleansing. 3. Perform passive and active ROM on all joints. 4. Provide pillows to sleep for patients with neck burns. 5. Perform exercises during and after wound cleansing.

3. Perform passive and active ROM on all joints. 5. Perform exercises during and after wound cleansing. Perform passive and active ROM on all joints to avoid contractures and prevent compromising on patient's cardiopulmonary status. It is not a good habit to practice physical therapy only occasionally. This is because continuous physical therapy throughout burn recovery is imperative if the patient needs to regain and maintain muscle strength and optimal joint function. A good time for exercise is during and after wound cleansing, when the skin is softer and bulky dressings are removed. Performing exercises before wound cleansing is not appropriate. Patients with neck burns should continue to sleep without pillows or with the head hanging slightly over the top of the mattress to encourage hyperextension and avoid contractures

A patient presents in the emergency department (ED) with burns on the hands and face after handling hydrochloric acid at work. What actions should the nurse perform toward the patient's burn management? Select all that apply. 1. Apply ice to the burned area. 2. Never wash the burn with water. 3. Remove all chemical particles on skin. 4. Remove all clothing containing the chemical. 5. Flush affected area with lots of water.

3. Remove all chemical particles on skin. 4. Remove all clothing containing the chemical. 5. Flush affected area with lots of water. Remove all chemical particles on skin to remove the burn-causing agent from the patient's body. Remove all clothing containing the chemical, as the burning process continues while the chemical is in contact with the skin. Flush affected area with copious amounts of water to irrigate the skin from 20 minutes to 2 hours after chemical exposure to clear off the chemical on or around the affected area. Applying ice to the burned area does not help to wash away the chemical. Washing the burnt area with water helps to clean off the chemical.

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.

4. Anticipate the need for endotracheal intubation and notify the health care provider. 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 endotracheal intubation and mechanical ventilation as this patient is demonstrating signs of severe respiratory distress. The nurse should also obtain vital signs and ABGs and insert a Foley, but these interventions are not a priority at this time. A sputum sample is not necessary at this time

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

4. High-calorie and high-protein foods 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.

A patient who sustained burn injuries is receiving daily treatments. He tells his caregiver, "The nurses enjoy hurting me." What should the nurse suspect? Choose the best answer. 1 This patient must be having hallucinations. 2 This patient might be having schizophrenia. 3 This patient has a serious psychiatric condition. Correct 4 This is a normal reaction to an extraordinary life event.

4. This is a normal reaction to an extraordinary life event Patients who have sustained burn injuries may experience a variety of emotions, including fear, anxiety, anger, guilt, and depression. The given example shows that the patient is angry and depressed, and it is important to reassure the patient and caregivers that these reactions may be normal and can be expected. The nurse should not assume from this reaction that the patient is experiencing hallucinations or any serious psychiatric conditions, including schizophrenia

Why does the nurse apply enzymatic débriding agents to a patient with severe wounds? 1 To decrease blood loss 2 To remove the old microbial agent 3 To protect the reepithelializing keratinocytes 4 To remove dead tissue from the healthy wound bed

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

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

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

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? A. 1 to 2 mL lactated Ringer's/kg/%TBSA burned B. 2 to 4 mL lactated Ringer's/kg/%TBSA burned C. 6 to 8 mL lactated Ringer's/kg/%TBSA burned D. 8 to 10 mL lactated Ringer's/kg/%TBSA burned

B. 2 to 4 mL lactated Ringer's/kg/%TBSA burned Fluid resuscitation is an important intervention in burn management. It helps to replenish the fluid loss caused by burns and maintain the fluid and electrolyte balance. The fluid recommendation for the first 24 hours is 2-4 mL lactated Ringer's/kg/%TBSA burned. A fluid volume of 1-2 mL lactated Ringer's/kg/%TBSA burned would be inadequate to meet the patient's requirement. Volumes of 6-8 mL lactated Ringer's/kg/%TBSA burned and 8-10 mL lactated Ringer's/kg/%TBSA burned may cause fluid overload.

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

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