HR: EAQ: Burn Injuries Mastery

A nurse is planning care for a patient with a 30% body surface area burn injury. Which statement by the nurse regarding the nutritional status of this patient is true?

"A hypermetabolic state results in poor healing and increased protein and lipid needs."

Which statement from a co-worker regarding the fluid and electrolyte shifts that occur during burn injuries requires correction by the nurse?

"Exudate is an example of second spacing."

A nurse is teaching a group of parents how to reduce the risk for injury related to burns. Which statement by a participant indicates effective learning?

"I should hold regular home fire exit drills."

A nurse is teaching a group of parents how to reduce the risk for scalding and inhalation burns. Which statement made by a participant indicates a need for further teaching?

"I should light candles near an open window."

Which statement made by a student nurse regarding clinical manifestations associated with severe burns indicates the need for further education by the nurse?

"The patient is unconscious and cannot answer until intubated."

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 expects to find which manifestation?

Reddening of the skin

A nurse is assessing a patient who was burned after contact with gasoline. Which complication would the nurse monitor?

Systemic toxicity

According to the Rule of Nines for calculating the percentage of burns, the nurse would assign which percentage to a burn in the genitalia?

1%

A patient has sustained burns on the face, neck, and chest. Which additional assessment findings would alert the nurse to an upper airway injury? Select all that apply.

Hoarseness Singed nasal hair Difficulty in swallowing

Which complications would the nurse assess for in a patient with metabolic asphyxiation? Select all that apply.

Hypoxia Hydrogen cyanide poisoning

The nurse is caring for a patient with burns covering the face, the entire right upper extremity, and the right upper trunk area. Using the Rule of Nines, the nurse would calculate the extent of these burns as which percentage

22.5%

For which complications would the nurse monitor an unconscious patient who suffered an electrical burn? Select all that apply.

Myoglobinuria Cervical spine injury Severe metabolic acidosis

A patient is admitted with severe burns over the front lower extremities, abdomen, chest, and both sides of the arms. Using the rule of nines, calculate the extent of the burn injuries. Fill in the blank using a whole number.

54%

Using the Rule of Nines, which percentage of burn surface area would the nurse document for a patient with burns over the entire surface of both arms, the anterior trunk, and the right leg?

54%

Which manifestations would the nurse expect when admitting a patient with a full thickness thermal burn?

No pain, waxy white skin, and no blanching with pressure

The nurse recalls which description as the most accurate regarding a deep partial-thickness burn?

Painful with weeping blisters

The nurse notes a patient who experienced a chemical burn is exhibiting decreased muscle coordination. The nurse would monitor the patient for which complication?

Paralysis

Which complication would the nurse monitor for in a burn injury patient who is experiencing premature ventricular contractions (PVCs) and shows signs of myoglobinuria?

Acute tubular necrosis (ATN)

Following fluid resuscitation, which parameter would indicate to the nurse that the patient is in a stable condition?

Systolic BP more than 90 mm Hg

A nurse is providing care to a patient with a partial-thickness burn. Which clinical manifestation would the nurse anticipate?

Damage to epidermis and dermis involving varying depths

Which clinical manifestation would the nurse anticipate due to thrombosis in the capillaries of the burned tissue of a patient?

Decreased erythrocyte count

A nurse notes decreased reflexes during the physical assessment of a patient who was admitted with a burn injury. Which is the likely cause for this clinical manifestation?

Decreased potassium levels

The nurse notes a bright-red area with blisters that blanches with the application of pressure on a burn patient. The patient reports severe pain when the burn is exposed to air. Which type of burn is present?

Deep partial-thickness burn

When caring for a patient with burns to the back, the nurse recognizes that the patient is moving out of the emergent phase of burn injury when which occurs?

Diuresis occurs and hematocrit decreases

The nurse would recognize which as clinical manifestations of a lower airway lung injury associated with burns? Select all that apply.

Dyspnea Wheezing Altered mental status

The nurse is reviewing the fluid and electrolyte shifts that occur during burn injury. Which of these occur during the emergent stage of a burn injury? Select all that apply.

Edema in nonburned areas (third spacing) Elevated hematocrit caused by hemoconcentration Movement of water and sodium to the interstitial fluid

A patient with a burn injury is brought to the emergency department, and the nurse notes white, leathery skin, dysrhythmias, and a loss of consciousness. Which type of burn injury would the nurse suspect?

Electrical

Which burn injury would the nurse identify as resulting in tissue anoxia?

Electrical injury

When assessing the patient with severe electrical burns, which symptoms does the nurse know would indicate this patient is hyperkalemic? Select all that apply.

Electrocardiogram (ECG) changes Muscle weakness Cardiac dysrhythmias

When assessing the patient with severe electrical burns, which symptoms does the nurse know would indicate this patient is hyperkalemic? Select all that apply

Electrocardiogram (ECG) changes Muscle weakness Cardiac dysrhythmias

A patient sustains a second-degree (partial-thickness) burn. Which layer(s) of skin would the nurse inspect for damage?

Epidermis and dermis

Which degree of burn would the nurse document for a patient with erythema, pain, and mild swelling following a burn injury?

First

Which type of burn injury would the nurse identify as occurring on the layers of subcutaneous fat, muscle, or deeper structures?

Full-thickness burn

Which clinical manifestations would the nurse anticipate while caring for a patient with third-degree burns? Select all that apply.

Hard, leathery skin Insensitivity to pain

Which clinical manifestations would the nurse observe in a patient during the emergent phase of a burn injury? Select all that apply.

Increased heart rate Decreased BP

Which pathophysiologic changes would the nurse anticipate while caring for a burn patient? Select all that apply.

Increased viscosity Decreased blood volume Increased vascular permeability

When assessing a patient suffering from inhalation burns on the face and chest, which findings would the nurse anticipate? Select all that apply

Increasing hoarseness Darkened oral or nasal membranes Productive cough with black sputum

A nurse is providing care to a patient who suffered burns to the perineum. Which would the nurse suspect the patient is at risk of developing?

Infection from urine contamination

A burn patient newly arrived at the emergency department is confused, has difficulty breathing, and has nasal burns. Which condition would the nurse suspect?

Lower airway injury

The nurse would monitor a patient who was injured using heavy industrial cleanser for which complications? Select all that apply

Melting Protein hydrolysis

The nurse would monitor a patient who was injured using heavy industrial cleanser for which complications? Select all that apply.

Melting Protein hydrolysis

A nurse working in a burn unit would identify which patients are at an increased risk of developing venous thromboembolism? Select all that apply

Morbid obesity Prolonged immobility

The nurse understands that which fluid and electrolyte change occurs during the early emergent phase of burn injury?

Movement of sodium and water into interstitial spaces

Which complication would the nurse be alert for in a patient with an electrical burn?

Myoglobinuria

A burn patient with moist, red, shiny vesicles and blister formation reports severe pain when the site is exposed to air. Which type of burn would the nurse document in the patient's medical record?

Second-degree burn

Laboratory tests indicate a burn patient is experiencing hypernatremia. Which clinical manifestations would the nurse monitor? Select all that apply.

Seizures Dried, furry tongue

A patient who sustained burns develops a paralytic ileus. Which would the nurse suspect to be the cause of this complication?

Sepsis

When assessing a patient with a second-degree burn, which clinical manifestations would the nurse anticipate? Select all that apply.

Severe pain Red, shiny vesicles Mild to moderate edema

Which characteristics of a second-degree thermal burn would the nurse expect to find during a patient's physical assessment? Select all that apply.

Severe pain Mild edema Fluid-filled vesicles

Which assessment findings would alert the nurse to the presence of an inhalation injury in a burn patient? Select all that apply.

Singed nasal hair Increasing hoarseness Painful swallowing History of being trapped in an enclosed space

The nurse is assessing a patient admitted after inhalation of toxic chemicals. Which finding by the nurse indicates a lower airway injury?

Singed nasal hairs

Which findings would the nurse expect a patient with full-thickness burns to exhibit? Select all that apply.

The patient is shivering The patient has low BP. The patient has absence of bowel sounds.

Which findings would the nurse expect a patient with full-thickness burns to exhibit? Select all that apply

The patient is shivering The patient has low BO The patient has absence of bowel sounds

Which factors lead the nurse to believe that a patient with severe burns on the legs and feet may have full-thickness burns? Select all that apply.

Touch sensation is impaired. Lack of blanching with pressure is observed. Wounds appear waxy white, dark brown, or charred.

While assessing a patient with severe burns, the nurse suspects hypokalemia. Which possible causes would the nurse evaluate? Select all that apply.

Vomiting IV therapy without potassium Prolonged gastrointestinal (GI) suction

The nurse suspects a burn injury patient has superficial partial-thickness burns. Which findings would the nurse expect to find? Select all that apply.

Wounds are red are painful There is blanching with pressure The burned area has minimal edema

Which characteristics would the nurse likely find when performing an examination of a patient's deep partial-thickness burn? Select all that apply.

Wounds are wet and shiny Wounds are painful to touch Wounds appear pink or cherry red