24

how is the immune system altered in a burn injury? a. bone marrow stimulation b. increase in immunoglobulin levels c. impaired function of white blood blood cells d. overwhelmed by microorganisms entering denuded tissue

c

how should the nurse position the patient with ear, face, and neck burns? a. prone b. on the side c. without pillows d. with extra padding around the head

c

which burn patient should have nasotrachela or endotracheal intubation? a. carbon monoxide poisoning b. electrical burns causing cardiac dysrhythmias c. thermal burn injuries to the face, neck, or airway d. respiratory distress from eschar formation around the chest

c

A nurse is planning care for an adult client who sustained severe burn injuries. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Limit visitors in the client's room. B. Encourage fresh vegetables in the diet. C. Increase protein intake. D. Instruct the client to consume 2,000 calories/day. E. Restrict fresh flowers in the room.

A,C,E

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 is the best action for the nurse to 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.

B

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

B

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 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). 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.

C

During the emergent phase of burn care, which assessment will be 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.

D

A nurse in a provider's office is assessing a client who has a severe sunburn. Which of the following classifications should the nurse use to document this burn? A. Superficial thickness B. Superficial partial thickness C. Deep partial thickness D. Full thickness

a

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 the patient's lung sounds. b. Determine the extent and depth of the burns. c. Give the prescribed hydromorphone (Dilaudid). d. Infuse the prescribed lactated Ringer's solution.

a

A therapeutic measure used to prevent hypertrophic scarring during the rehabilitation phase of burn recovery 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

a

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

a

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 95.2° F (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.

a

The injury that is least likely to result in a full-thickness burn is a. sunburn b. scald injury c. chemical burn d. electrical injur

a

a patient with deep partial-thickness burns over 45% of his trunk and legs is going for debridement in the cart shower 48 hours post burn. what is the drug of choice to control the patient's pain during this activity? a. IV morphine b. midazolam (versed) c. IM meperidine (demerol) d. long-acting oral morphine

a

during the early emergent phase of burn injury, the patients laboratory results would most likely include a. increased Hct, decreased serum albumin, decrease serum Na, increase serum K b. decrease in Hct, decrease in albumin, decrease in Na, decrease in K c. decrease in Hct, increase in Albumin, increase in Na, increase in K d. increase in Hct, Increase in albumin, decrease in Na, decrease in K

a

during the rehabilitation phase of a burn injury what can control the contour of the scarring? a. pressure garments b. avoidance of sunlight c. splinting joints in extension d. application of emollient lotions

a

o maintain a positive nitrogen balance in a major burn, the patient must a. eat a high-protein, 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 a gluten-free diet for the chemical effect on nitrogen balance

a

the burn patient has developed an increasing dread of painful dressing changes. what would be the most appropriate treatment to ask the health care provider to prescribe? a. midazolam to be used with morphine before dressing changes b. morphine in a dosage range so that more may be given before dressing changes c. buprenorphine to be administered with morphine before dressing changes d. patient-controlled analgesia so that the patient may have control of analgesic administration

a

the nurse initially suspects the possibility of sepsis in the burn patient based on what changes? a. vital signs b. urinary output c. gastrointestinal function d. burn wound appearance

a

what is the initial cause of hypovolemia during the emergent phase of burn injury? a. increased capillary permeability b. loss of sodium to the interstitium c. decreased vascular oncotic pressure d. fluid loss from from denuded skin surfaces

a

when assessing a patient's full-thickness burn injury during the emergent phase, what would the nurse expect to find? a. leathery, dry, hard skin b. red, fluid-filled vesicles c. massive edema at the injury site d. serous exudate on a shiny, dark brown wound

a

When assessing a patient with a partial-thickness burn, the nurse would expect to find (select all that apply) a. blisters b. exposed fascia c. exposed muscles d. intact nerve endings e. red, shiny, wet appearance

a,b,d

A nurse is assessing a client who sustained deep partial‐thickness and full‐thickness burns over 40% of his body 24 hr ago. Which of the following are findings should the nurse expect? (Select all that apply.) A. Dyspnea B. Bradycardia C. Hyperkalemia D. Hyponatremia E. Decreased hematocrit

a,c,d

Pain management for the burn patient is most effective when (select all that apply) 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 pain d. a multimodal approach is used (e.g., sustained-release and short-acting opioids, NSAIDs, adjuvant analgesics) e. nonpharmacologic therapies (e.g., music therapy, distraction) replace opioids in the rehabilitation phase of a burn injury

a,c,d

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.

b

A patient has 25% TBSA burn 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

b

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

b

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.

b

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.

b

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 by the nurse is best? 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."

b

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 (202.4 lb). 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.

b

The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine output has dramatically increased. Which action by the nurse would best support maintaining kidney function? a. Monitor white blood cells (WBCs). b. Continue to measure the urine output. c. Assess that blisters and edema have subsided. d. Encourage the patient to eat an adequate number of calories.

b

Which patient should the nurse assess first? a. A patient with burns who is complaining of 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

b

Which type of burn injury would cause myoglobinuria, long bone fractures, and cardiac dysrhythmias and/or cardiac arrest? a. thermal b. electrical c. chemical d. smoke and inhalation

b

While the patient's full-thickness burn wounds to the face are exposed, what nursing action prevents cross contamination? a. Use sterile gloves when removing dressings. b. Wear gown, cap, mask, and gloves during care. c. Keep the room temperature at 70° F (20° C) at all times. d. Give IV antibiotics to prevent bacterial colonization of wounds.

b

a burn patient has a nursing diagnosis of impaired physical mobility related to a limited range of motion resulting from pain. what is an appropriate nursing intervention for this patient? a. have the patient perform ROM exercises when pain is not present b. provide anlagesic medications before physical activity and exercise c. teach the patient the importance of exercise to prevent contractures d. arrange for the physical therapist to encourage exercise during hydrotherapy

b

a patient's deep partial-thickness burns are treated with the open method. what should the nurse do when caring for the patient? a. ensure that sterile water is used in the debridement tank b. wear a cap, mask, gown, and gloves during patient contact c. use sterile gloves to remove the dressings and wash the wounds d. apply topical antimicrobial ointment with clean gloves to prevent wound trauma

b

the nurse assess the bowel sounds are absent and abdominal distention is present in a patient 12 hour post-burn. the nurse notifies the health care provider and anticipates doin what action next? a. withhold all oral intake except water b. insert a nasogastric tube for decompression c. administer a H2- histamine blocker such as rantanadine d. administer nutritional supplements through a feeding tube placed in the duodenum

b

the patient was admitted to the burn center with a full-thickness burn 42 hours after the thermal burn occurred. the nurse will apply actions related to which phase of burn management for this patient's care? a. acute b. emergent c. postacute d. rehabilitative

b

what is one clinical manifestation the nurse would expect to find during the emergent phase in a patient with a full-thickness burn over the lower half of the body? a. fever b. shivering c. severe pain d. unconsciousnes

b

identify the factors that increase nutritional needs of the patient during the emergent and acute phases of burn injury a. electrolyte imbalance b. core temp elevation c. calories and protein are used for tissue repair d. hypometabolic state secondary to decreased GI function e. massive catabolism characterized by protein breakdown and increased gluconeogenesis

b,c,e

A nurse is caring for a client who has sustained burns over 35% of his total body surface area. Of this total, 20% are full‐thickness burns on the arms, face, neck, and shoulders. The client's voice has become hoarse. He has a brassy cough and is drooling. The nurse should identify these findings as indications that the client has which of the following? A. Pulmonary edema B. Bacterial pneumonia C. Inhalation injury D. Carbon monoxide poisoning

c

A nurse is preparing to administer fentanyl to a client who sustained deep partial‐thickness and full‐thickness burns over 60% of his body 24 hr ago. The nurse should plan to use which of the following routes to administer the medication? A. Subcutaneous B. Oral C. Intravenous D. Transdermal

c

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

c

A patient is recovering from second- and third-degree burns over 30% of his body and the burn care team is planning 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 the 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 information and websites for information for burn survivors

c

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

c

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

c

A young adult patient who is in the rehabilitation phase after having deep partial-thickness face and neck burns has a nursing diagnosis of disturbed body image. 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."

c

Esomeprazole (Nexium) 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

c

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 the vascular space c. sequestering of sodium and water in interstitial fluid d. hemolysis of red blood cells from large volumes of rapidly administered fluid

c

Knowing the most common causes of household fires, which prevention strategy would the nurse focus on when teaching about fire safety? a. Set hot water temperature at 140F b. Use only hardwired smoke detectors c. Encourage regular home fire exit drills d. Never permit older adults to cook unattended

c

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 mEq/L c. Serum potassium of 6.1 mEq/L d. Blood urea nitrogen of 37 mg/dL

c

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.

c

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

c

a 24-year old female patient does not want the wound cleansing and dressing change to take place. she states, "what difference will it make anyway?" what will the nurse encourage the patient to do? a. have the wound cleaned and the dressing changed b. have a snack before having the treatments completed c. talk about what is troubling her with the nurse and/or family d. call the chaplain to com and talk to her and convince her to have the care

c

at the end of the emergent phase and the initial acute phase of burn injury, a patient has a serum sodium level of 152 mEq/L and a serum potassium level of 2.8 mEq/L. What could have caused these imbalances? a. free oral water intake b. prolonged hydrotherapy c. mobilization of fluid and electrolytes in the acute phase d. excessive fluid replacement with dextrose in water without potassium supplementation

c

A patient is admitted to the burn center with burns to his head, neck, and anterior and posterior chest 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 he most appropriate for the nurse to take next? a. Encourage the patient to cough and auscultate the lungs again b. Obtain vital signs, oxygen saturation, and a STAT arterial blood gas c. Document the findings and continue to monitor the patient's breathing d. Anticipate the need for endotracheal intubation and notify the physician

d

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.

d

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. Assess for singed nasal hair and dark oral mucous membranes. d. Place the patient on 100% O2using a nonrebreather mask.

d

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.

d

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 (Ativan) c. gabapentin (Neurontin) d. hydromorphone (Dilaudid)

d

a patient has a 20% TBSA deep partial-thickness and full-thickness burn to the right anterior chest and entire right arm. what is important for a nurse to assess in this patient?a. presence of pain b. swelling of the arm c. formation of eschar d. presence of pulses in the arms

d

Which characteristics are true about chemical burns? a. metabolic asphyxiation may occur b. metabolic acidosis occurs immediately following the burn c. the visible skin injury often does not represent the full extent of tissue damage d. lavaging with large amounts of water is important to stop the burning process with these injuries e. alkaline substances that cause these burns continue to cause tissue damage even after being neutralized

d,e