Burns AQ
A patient is brought to the emergency department after an automobile accident with severe burns over the front lower extremities, abdomen, chest, and both sides of the arms. Using the rule of nines chart, calculate the extent of the burn injuries. Fill in the blank using a whole number.
54 Refer to Figure 25-4B. The front of each lower extremity would be 18% (9% each); the abdomen/chest area would be 18%; both sides of both arms would be 18% (4.5% for each side of each arm). 18 + 18 + 18 = 54%.
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? First degree Second degree Third degree Fourth degree
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
An unconscious patient who suffered an electrical burn is admitted to the emergency department. For which complications will the nurse monitor? Select all that apply. Myoglobinuria Systemic toxicity Pulmonary edema Cervical spine injury Severe metabolic acidosis
Myoglobinuria Cervical spine injury Severe metabolic acidosis Patients with an electrical injury are at risk from myoglobinuria, cervical spine injury, and severe metabolic acidosis. Myoglobinuria occurs because myoglobin from the injured tissue is released into circulation, causing muscle and blood vessel damage. Contact with electrical currents causes muscle contractions, which can fracture the vertebrae and bones. Electrical injury carries the risk of severe metabolic acidosis. Systemic toxicity occurs in patients with chemical burns. Pulmonary edema occurs due to smoke and inhalation injuries.
The ambulance reports that it is transporting a patient to the emergency department who has experienced a full-thickness thermal burn from a grill. What manifestations should the nurse expect? Severe pain, blisters, and blanching with pressure Pain, minimal edema, and blanching with pressure Redness, evidence of inhalation injury, and charred skin No pain, waxy white skin, and no blanching with pressure
No pain, waxy white skin, and no blanching with pressure 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.
A patient with a burn inhalation injury is receiving albuterol for bronchospasm. What is the most important adverse effect of this medication for the nurse to manage? Tachycardia Hypokalemia Restlessness Gastrointestinal (GI) distress
Tachycardia Albuterol stimulates beta 2 receptors in the lungs to cause bronchodilation. However, it is a non-cardioselective agent so it also stimulates the beta 2 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.
A patient who sustained burn injuries is receiving daily treatments. The patient tells the caregiver, "The nurses enjoy hurting me." What should the nurse suspect? Choose the best answer. This patient must be having hallucinations. This patient might be having schizophrenia. This patient has a serious psychiatric condition. This is a normal reaction to an extraordinary life event.
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.
While teaching care guidelines to a family member of a patient with burns, the nurse instructs the family member to include foods rich in omega-3 fatty acids in the patient's diet. What is the rationale behind the nurse's instruction? To improve sleep To prevent blood clots To promote weight gain To decrease stomach acid
To prevent blood clots A patient with severe burns is at greater risk of venous thromboembolism. Omega-3 fatty acids are natural anticoagulants that decrease platelet aggregation. Eating foods rich in tryptophan, not omega-3 fatty acids, improves the patient's sleeping pattern. Tryptophan is an amino acid that blocks body wakeup cycles and promotes sleep. Foods rich in protein and fats, like peanut butter and red meat, help the patient gain weight. Avoiding spicy foods and drinking plenty of pure water helps decrease stomach acid.
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. Touch sensation is impaired. Blanching with pressure is observed. Lack of blanching with pressure is observed. Wounds appear mottled white, pink to cherry-red. Wounds appear waxy white, dark brown, or charred.
Touch sensation is impaired. Lack of blanching with pressure is observed. 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, because all skin elements are destroyed. Wounds appear waxy white, dark brown, or charred in full-thickness burns, because 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 teaching a group of parents how to reduce the risk for injury related to burns. Which statement by a participant indicates effective learning? "Frayed wires are OK to use at home." "I should hold regular home fire exit drills." "I should use gasoline with care to start a fire." "I should perform outdoor activities with caution during electrical storms."
"I should hold regular home fire exit drills." Regular home fire exit drills ensure the family knows the primary escape routes in case of any flame accidents at home. Frayed wires lack protective insulation, and contact may result in electrical injuries. Gasoline or kerosene should never be used to start a fire. Outdoor activities should be avoided during electrical storms.
Which statement made by a student nurse regarding clinical manifestations associated with severe burns indicates the need for further education? "The patient's altered mental status is due to hypoxia." "The patient with larger burns may develop paralytic ileus." "The patient with severe burns is most likely to be in shock." "The patient is unconscious and cannot answer until intubated."
"The patient is unconscious and cannot answer until intubated." The patient with severe burns may have shifting levels of consciousness. However, once the patient is intubated he or she will not be able to answer questions verbally. This statement indicates the need for further education. Altered mental status results from hypoxia. Paralytic ileus occurs in patients with larger burns. The patient with severe burns is in shock.
A nurse works in an emergency department. Which patients are appropriate for the nurse to refer to the burn care unit? Select all that apply. A patient with burns of the feet A patient with an inhalation injury An elderly patient with third-degree burns A patient with burns involving minor joints A patient with partial thickness burns involving 8% of total body surface area
A patient with burns of the feet A patient with an inhalation injury An elderly patient with third-degree burns A burn care unit provides advanced care to burn patients to prevent complications and keep the condition from worsening. Inhalation injury increases the risk of airway obstruction and requires a referral to the burn unit. Burns of both feet is associated with complications like contractures, and needs to be referred to the burn care unit. Third-degree burns in any age-group require referral. Burns involving minor joints do not require referral to burn centers; however, burns of major joints require referral. Partial thickness burns require referral if they involve more than 10% of the body surface area.
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. Avoid using topical antibiotics. Administer a tetanus antitoxin. Perform debridement as required. Avoid using antimicrobial dressings. Assess the extent and depth of the burns.
Administer a tetanus antitoxin Perform debridement as required. Assess the extent and depth of the burns. 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. Antacids Antidiarrheal H 2-histamine blockers Proton pump inhibitors Calcium channel blockers
Antacids H 2-histamine blockers Proton pump inhibitors Antacids are used prophylactically to neutralize the acids present in the stomach. H 2-histamine blockers (e.g., ranitidine) are used to inhibit histamine, which causes an increase in acid levels. Proton pump inhibitors (e.g., esomeprazole) 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. Antidiarrheals are useful in providing symptomatic relief for diarrhea. They 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 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? Insert a Foley catheter and monitor output. Obtain vital signs and a stat arterial blood gas (ABG). Obtain a sputum specimen and send it to the lab stat. Anticipate the need for endotracheal intubation and notify the health care provider.
Anticipate the need for endotracheal intubation and notify the health care provider. Inhalation injury results from 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, because 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.
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. What would be the nurse's priority intervention for wound care at this time? Reapply a new dressing without disturbing the wound bed. Apply fine-meshed petroleum gauze to the debrided areas. Wash the wound aggressively with sterile saline three times a day. Apply cool compresses for pain relief in between dressing changes.
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.
When attending to a patient with severe burns, what precautions should the nurse take to maintain adequate nutrition? Select all that apply. Assess respiratory rate every two hours. Assess bowel sounds every eight hours. Begin large amounts of feeding within first six hours. Begin early enteral feeding with smaller-bore tubes. Begin the feedings slowly at a rate of 20 to 40 mL/hr.
Assess bowel sounds every eight hours. Begin early enteral feeding with smaller-bore tubes. Begin the feedings slowly at a rate of 20 to 40 mL/hr. The nurse should assess bowel sounds every eight hours to ensure proper functioning of the bowels before starting oral nutrition. The nurse should also begin early enteral feeding with smaller-bore tubes, because this preserves gastrointestinal (GI) function, increases intestinal blood flow, and promotes optimal conditions for wound healing. The feedings should begin slowly at a rate of 20 to 40 mL/hr to protect the GI function and gradually increase as the patient improves. Assessing the respiratory rate every two hours is not related to nutritional therapy. Large amounts of feeding within the first six hours may overload the system and affect the GI function.
A patient has thermal burns on the face, including the cheeks and the area around the eyes. Which measures should the nurse take? Instill artificial tears in each eye. Wrap sterile gauze around his face. Cover the face with silver sulfadiazine ointment and gauze. Apply silver sulfadiazine ointment only without the use of gauze.
Cover the 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.
A nurse is assessing a patient with a burn injury. Which clinical manifestation does the nurse anticipate due to thrombosis in the capillaries of the burned tissue? Elevated heart rate Elevated hematocrit Decreased blood pressure Decreased erythrocyte count
Decreased erythrocyte count Thrombosis in the capillaries of burned tissue results in a loss of circulating erythrocytes (RBCs). An elevated heart rate and decreased blood pressure are signs of hypovolemic shock, which is caused by a massive shift of fluids out of the blood vessels. Hematocrit is elevated in burn injuries due to the hemoconcentration that results from fluid loss.
A patient sustains a second-degree (partial-thickness) burn. Which layer(s) of skin does the nurse inspect for damage? Epidermis only Muscle and bone Epidermis and dermis Epidermis, dermis, and subcutaneous tissue
Epidermis and dermis In a second-degree, or partial-thickness, burn, both the epidermis and dermis are damaged. A first-degree superficial burn, such as sunburn, involves only the epidermis. A third- or fourth-degree full-thickness burn may involve muscle and bone. A third-degree deep partial- to full-thickness burn may include the epidermis, dermis, and subcutaneous tissue.
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. Escharotomy Administration of diuretics Daily cleansing and debridement Application of topical antimicrobial agent Intravenous (IV) and oral pain medications
Escharotomy Daily cleansing and debridement Application of topical antimicrobial agent Intravenous (IV) and oral pain medications Pain control is essential in the care of a patient with a burn injury. Daily cleansing and debridement, as well as application of an antimicrobial ointment, are expected interventions used to minimize infection and enhance wound healing. An escharotomy (a scalpel incision through full-thickness eschar) frequently is required to restore circulation to compromised extremities. With full-thickness burns, myoglobin and hemoglobin released into the bloodstream can occlude renal tubules. Adequate fluid replacement is used to prevent this occlusion.
A nurse is providing care to a patient who was admitted to the hospital with third-degree burns. Which clinical manifestations should the nurse anticipate? Select all that apply. Erythema Fluid-filled vesicles Hard, leathery skin Insensitivity to pain Mild to moderate edema
Hard, leathery skin Insensitivity to pain Third-degree burns cause full-thickness skin destruction. Clinical manifestations include hard, leathery skin and insensitivity to pain due to nerve destruction. Erythema is observed in first-degree burns. Second-degree burns are characterized by fluid-filled vesicles and mild to moderate edema.
For a patient with chemical burn of 15% total body surface area (TBSA) on the legs, what kind of food should be encouraged? High fat and high carbohydrate Low protein and low carbohydrate High protein and low carbohydrate High protein and high carbohydrate
High protein and high carbohydrate The patient with chemical burn of 15% TBSA should be encouraged to eat a high-protein, high-carbohydrate diet. Foods high in protein and high in carbohydrates are important for tissue regeneration and promote wound healing. The daily estimated caloric needs should be calculated and regularly reassessed according to the patient's changing condition.
A nurse is triaging a patient who has arrived in the emergency department with burns as a result of a fire. Which patient symptoms indicate an upper airway injury? Select all that apply. Dyspnea Hoarseness Difficulty swallowing Copious secretions Carbonaceous sputum
Hoarseness Difficulty swallowing Copious secretions An inhalation injury in the upper airways involves the mouth, oropharynx, and/or larynx. It may cause hoarseness in the voice due to the effect on the larynx. There may be difficulty in swallowing due to involvement of the mouth and oropharynx. There may be copious secretion in response to the injury to the airway. The injury to the lower airway involves trachea, bronchioles, and alveoli, and may cause carbonaceous sputum and dyspnea.
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. Dyspnea Wheezing Hoarseness Singed nasal hair Difficulty in swallowing
Hoarseness Singed nasal hair 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
Which clinical manifestations are observed in a patient in the emergent phase of a burn injury? Select all that apply. Increased appetite Increased heart rate Increased urine output Decreased respiratory rate Decreased blood pressure
Increased heart rate Decreased blood pressure During the emergent phase of a burn injury, the patient exhibits tachycardia and hypotension. Other clinical manifestations during this phase include a loss of appetite, a decreased urine output, and tachypnea.
When assessing a patient suffering from inhalation burns on the face and chest, what findings should a nurse anticipate? Select all that apply. Increasing hoarseness Location of contact points Leathery white charred skin Darkened oral or nasal membranes Productive cough with black sputum
Increasing hoarseness Darkened oral or nasal membranes 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 nurse is providing care to a patient who suffered burns to the perineum. For what is the patient at risk of developing? Infection to the respiratory tract Infection from urine contamination Infection to the vascular and nerve supply Infection because of poor blood supply to the cartilage
Infection from urine contamination The perineum is the part of the body occupied by urogenital passages and the rectum. A patient with burns to the buttocks or perineum is at an increased risk for infection from urine or feces contamination. A patient with burns to the face and neck is susceptible to infection of the respiratory tract. Burns to the hands and feet put the patient at risk for infection of the vascular and nerve supplies. Infection because of poor blood supply to the cartilage is found in patients with ear and nose burns.
A patient with burns needs permanent skin grafting. Which grafts should the nurse consider? Select all that apply. Integra AlloDerm Autograft Homograft Heterograft
Integra AlloDerm Autograft ntegra is obtained from bovine collagen and glycosaminoglycan bonded to silicone and gives permanent coverage. AlloDerm is obtained from a cellular dermal matrix derived from donated human skin and can be used for permanent grafting. Autograft is from patient's own skin and can be used for permanent grafting. Homograft is obtained from cadaveric skin and can be used as temporary graft from 3 days to 2 weeks. Heterograft is obtained from porcine skin and can be used as temporary graft from three days to two weeks.
A nurse is attending to a patient with burns. When considering the use of antibiotics, what factors does the nurse consider? Select all that apply. It is essential to check the patient for allergies to sulfa. Systemic antibiotics are routinely used to control burn wound flora. Silver-impregnated dressings can be left in place from 3 to 14 days. Silver sulfadiazine or mafenide acetate creams should never be used. Topical antimicrobial agents may be applied after the wound cleansing.
It is essential to check the patient for allergies to sulfa. Silver-impregnated dressings can be left in place from 3 to 14 days. Topical antimicrobial agents may be applied after the wound cleansing The nurse should assess for a sulfa allergy, because some prescribed antibiotics may contain sulfa. Silver-impregnated dressings can be left in place from 3 to 14 days, depending on the patient's clinical situation and the particular product. Topical antimicrobial agents may be applied after the wound cleansing to facilitate healing, and then the affected area should be covered with a light dressing. Systemic antibiotics are not routinely used to control burn wound flora, because the burn eschar has little or no blood supply, and consequently, little antibiotic is delivered to the wound. Also, the routine use of systemic antibiotics increases the chance of developing multidrug-resistant organisms. Silver sulfadiazine and mafenide acetate creams are also used as burn antimicrobial creams.
A burn patient is about to receive a dressing change. The patient has dressings over both feet and lower legs and is receiving a continuous infusion of hydromorphone. Which medication(s) is/are appropriate for the patient to receive before the dressing change is started? Select all that apply. Lorazepam, an anxiolytic Slow-release oral morphine Zolpidem, a sleep-inducing hypnotic Intravenous fentanyl, a short-acting opioid The patient will not need additional medication because the patient is receiving a continuous opioid infusion.
Lorazepam, an anxiolytic Intravenous fentanyl, a short-acting opioid Burn patients experience two kinds of pain: (1) continuous, background pain that might be present throughout the day and night; and (2) treatment-induced pain associated with dressing changes, ambulation, and rehabilitation activities. With background pain, a continuous intravenous (IV) infusion of an opioid (e.g., hydromorphone) allows for a steady, therapeutic level of medication. For treatment-induced pain, premedicate with an analgesic and an anxiolytic via the IV or oral route. For patients with an IV infusion, a potent, short-acting analgesic, such as fentanyl, often is effective. If an IV infusion is not present, slow-release, twice-a-day opioid medications (e.g., morphine) are indicated. The morphine would not be appropriate for this patient, because the patient is receiving an IV pain medication infusion. A sleeping pill is not appropriate at this time.
A patient who escaped from a burning building, which was enclosed with no ventilation, is brought to the emergency department. The patient is confused, has difficulty breathing, and has nasal burns. Which condition does the nurse suspect? Pulmonary edema Lower airway injury Upper airway injury Carbon monoxide poisoning
Lower airway injury A patient who was trapped in an enclosed burning building with no ventilation and is exhibiting confusion, dyspnea, and nasal burns is most likely experiencing a lower airway burn injury. Pulmonary edema may occur but not until 12 to 24 hours after the initial insult. Clinical manifestations of an upper airway injury include blisters, edema, difficulty in swallowing, and total airway obstruction. Carbon monoxide poisoning results in hypoxia, in which oxygen consumption is impaired.
The patient in the acute phase of burn care has electrical burns on the left side of the 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? Maintain a neutral pH Maintain fluid balance Replace the blood lost Replace serum potassium
Maintain fluid balance This patient most likely is experiencing hyperosmolar hyperglycemic syndrome (HHS). HHS dehydrates a patient rapidly. Thus HHS combined with the massive fluid losses of a burn tremendously increases 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.
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 progresses from the emergent phase? Monitor for signs of complications Assess and manage pain and anxiety Discuss possible reconstructive surgery Begin intravenous (IV) fluid replacement
Monitor for signs of complications 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.
When teaching patients and caregivers about the strategies to reduce burn injuries, what essential instructions does the nurse give? Select all that apply. Perform outdoor activities during lightning storms. Never leave burning candles unattended or near windows or curtains. Ensure an electrical power source is shut off before beginning repairs. Check temperature of bath water with the back of hand or bath thermometer. Store chemicals in the lowest shelves to avoid mixing up with other household chemicals.
Never leave burning candles unattended or near windows or curtains Ensure an electrical power source is shut off before beginning repairs. 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.
The emergency department nurse is caring for a patient whose skin is discolored and edematous, and the patient is exhibiting decreased muscle coordination. Which complication is the patient at risk of developing? Paralysis Cardiac fibrillation Acute tubular necrosis Acute respiratory distress
Paralysis Discoloration of skin, edema, and decreased muscle coordination indicate chemical burns. Chemical burns occur due to contact with acids, alkalis, or organic compounds. Chemicals that remain in contact with the skin for a long time reach the nerve supply, which can result in paralysis. Cardiac fibrillation and acute tubular necrosis may occur in patients with electrical injury. Acute respiratory distress may be observed in patients with smoke or inhalation injury to the lower airways.
When planning for burn management, which patients should the nurse refer to a burn center? Select all that apply. Patients with hydrochloric acid burns Patients of all ages with first-degree burns Patients of all ages with third-degree burns Patients with 25% deep partial-thickness burns Patients with 5% superficial partial-thickness burns
Patients with hydrochloric acid burns Patients of all ages with third-degree burns 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, because 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 is brought to the emergency department (ED) with a history of inhalation injury from hot air in a manufacturing unit. The patient has also sustained burns on the face, neck, and hands. What actions should the nurse perform immediately? Select all that apply. Wait for laboratory reports. Observe for the next two hours. Perform early endotracheal intubation. Observe for signs of respiratory distress. Check for evidence of inhalation of smoke.
Perform early endotracheal intubation. Observe for signs of respiratory distress. Check for evidence of inhalation of smoke. Checking for smoke inhalation is an important step to evaluate burn victims. Also, looking out for signs of respiratory distress like increased agitation, anxiety, restlessness, or a change in the rate or character of breathing is important. Early treatment includes airway management that involves early endotracheal (preferably orotracheal) intubation, because it eliminates the need for an emergency tracheostomy. Observing the patient for the next two hours does not help because treatment must begin at the earliest possible moment. In general, the patient suffering from burns on the face and neck may have mechanical obstruction caused by massive swelling of the tissues and requires intubation within one to two hours after the injury.
While planning physical therapy for a patient suffering from burns, which should be included? Select all that apply. Perform exercises before wound cleansing. Practice physical therapy only occasionally. Perform passive and active ROM on all joints. Provide pillows to sleep for patients with neck burns. Perform exercises during and after wound cleansing.
Perform passive and active ROM on all joints. Perform exercises during and after wound cleansing. Perform passive and active ROM on all joints to avoid contractures and prevent compromising the 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 who had a burn injury two days ago over 35% of the body is in the intensive care unit. The patient is intubated, on a mechanical ventilator, and fluid status is stable. Which of these interventions will the nurse anticipate for the patient's nutrition? Start total parenteral nutrition. Provide enteral tube feeding, starting at 20 mL/hour. Provide bolus enteral tube feedings four times a day. Feed at least 1500 calories/day in small, frequent meals.
Provide enteral tube feeding, starting at 20 mL/hour. Nonintubated patients with a burn of less than 20% total body surface area (TBSA) will generally be able to eat enough to meet their nutritional needs. Intubated patients and those with larger burns require additional support. Enteral feedings (gastric or intestinal) have almost entirely replaced parenteral feeding. Early enteral feeding, usually with smaller-bore tubes, preserves gastrointestinal (GI) function, increases intestinal blood flow, and promotes optimal conditions for wound healing. In general, begin the feedings slowly at a rate of 20 to 40 mL/hr and increase to the goal rate within 24 to 48 hours.
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. Severe pain Mild edema Fluid-filled vesicles Waxy, white, hard skin Visible thrombosed vessels
Severe pain Mild edema Fluid-filled vesicles 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 providing care to a patient who presents with a scald burn injury. When assessing this patient, which clinical manifestations should the nurse anticipate? Select all that apply. Blanching Severe pain White, waxy skin Red, shiny vesicles Mild to moderate edema
Severe pain Red, shiny vesicles Mild to moderate edema Scald burn injuries cause second-degree burns. Clinical manifestations of second-degree burns include severe pain, the appearance of fluid-filled vesicles, the appearance of "shiny" skin, and mild to moderate edema. Blanching is observed in first-degree burns, and white, waxy skin is seen in third- and fourth-degree burns.
A nurse is assessing four patients who have sustained respiratory injuries as a result of smoke inhalation. Which patient is exhibiting symptoms of an upper airway injury? Stridor Dyspnea Carbonaceous Sputum Presence of facial burns and singed nasal and facial hair
Stridor An upper airway injury is a type of smoke or inhalation injury that affects the mouth, oropharynx, or larynx. Stridor is associated with this type of injury; therefore the nurse suspects that patient 1 has an upper airway burn injury. Dyspnea, carbonaceous sputum, facial burns, and signed facial or nasal hairs are observed in patients with lower airway injuries.
Why does the nurse apply enzymatic debriding agents to a patient with severe wounds? To decrease blood loss To remove the old microbial agent To protect the reepithelializing keratinocytes To remove dead tissue from the healthy wound bed
To remove dead tissue from the healthy wound bed Enzymatic debriding agents are made of natural products like collagen. Enzymatic debriding 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 re-epithelializing keratinocytes from damage. This dressing resurfaces and closes the open bed wound.
The nurse is providing education to a patient who is in the rehabilitation phase of burn recovery after burning the arm with scalding water. Which of these statements by the patient indicates a need for further instruction? "If the area itches, I can apply a water-based moisturizer." "After a month, I will be able to go to the beach to get a tan." "I will need to wear the pressure garment for 24 hours a day." "I will continue the range-of-motion exercises on a regular schedule."
"After a month, I will be able to go to the beach to get a tan." Burn patients must protect healed burn areas from direct sunlight for about three months to prevent hyperpigmentation and sunburn injury. They should always wear sunscreen when they are outside. Water-based moisturizers are appropriate for itching. Pressure garments and masks should never be worn over unhealed wounds and, once a wearing schedule has been established, are removed only for short periods while bathing. Pressure garments are worn up to 24 hours a day for as long as 12 to 18 months. The range-of-motion exercises are important to prevent contractures that may develop as new tissue shortens.
A patient with a flash burn injury is admitted to the emergency department. The nurse notes a bright red area with blisters that blanches with the application of pressure. The patient also reports severe pain when the burn is exposed to air. Which type of burn is present? Superficial burn Full-thickness burn Deep partial-thickness burn Superficial partial-thickness burn
Deep partial-thickness burn A bright red area with blisters, blanching upon pressure, and severe pain in the patient indicates a deep partial-thickness burn. Superficial and superficial partial-thickness burns are characterized by erythema, but no blisters, with pain and mild swelling. Full-thickness burns are characterized by dry, waxy, leathery skin that is insensitive to pain due to nerve destruction.
A patient with a burn injury is brought to the emergency department. The nurse notes white, leathery skin, dysrhythmias, and a loss of consciousness. Which type of burn injury does the nurse suspect? Thermal Electrical Chemical Inhalational
Electrical Electrical burns occur from the intense heat of an electrical current. Electrical burns present with dry and leathery skin, dysrhythmia, and a loss of consciousness. Thermal burns occur due to hot liquids or flames, resulting in skin injuries ranging from superficial to full-thickness. Chemical burns cause protein damage and liquefaction. Inhalation injury, which results from breathing hot air or harmful chemicals, causes respiratory tract damage.
To determine the adequacy of fluid resuscitation in patients who have sustained burns, the nurse should assess which measurements of cardiac parameters? Select all that apply. Heart rate less than 120 beats/minute Manual systolic BP greater than 90 mm Hg Arterial line systolic BP greater than 90 mm Hg Manual mean arterial pressure greater than 65 mm Hg Arterial line mean arterial pressure greater than 65 mm Hg
Heart rate less than 120 beats/minute Arterial line systolic BP greater than 90 mm Hg Arterial line mean arterial pressure greater than 65 mm Hg The cardiac parameters which help to assess adequacy of fluid resuscitation are heart rate less than 120 beats/minute, arterial line systolic blood pressure greater than 90 mm Hg, and arterial line mean arterial pressure greater than 65 mm Hg. Manual blood pressure and manual mean arterial blood pressure are invalid in burns because of edema and vasoconstriction.
Which complications occur in a patient with metabolic asphyxiation? Select all that apply. Hypoxia Cardiac standstill Protein hydrolysis Hydrogen cyanide poisoning Acute respiratory distress syndrome
Hypoxia Hydrogen cyanide poisoning Metabolic asphyxiation is a type of smoke and inhalation injury that occurs due to inhalation of carbon monoxide or hydrogen cyanide. In this condition, the oxygen delivery or consumption is impaired, resulting in hypoxia. Hydrogen cyanide poisoning also occurs in metabolic asphyxiation in the absence of burn injury to the skin. Cardiac standstill occurs in an electrical injury. Protein hydrolysis occurs in a chemical injury. Acute respiratory distress syndrome occurs in a lower airway injury.
A nurse is assessing a patient who was injured using heavy industrial cleanser while working at a factory. For which complications will the nurse monitor? Select all that apply. Hypoxia Liquefaction Tissue anoxia Protein hydrolysis Metabolic acidosis
Liquefaction Protein hydrolysis A chemical burn results from contact with an alkali, such as an industrial cleanser. When the alkalis come in contact with skin, they adhere to the tissue, resulting in protein hydrolysis and liquefaction. Hypoxia occurs in smoke and inhalation injuries. Tissue anoxia and metabolic acidosis occur in patients with electrical burns.
Which fluid and electrolyte change occurs during the early emergent phase of burn injury? Increased excretion of urine Increased colloidal osmotic pressure Return of interstitial fluid to the vascular space Movement of sodium and water into interstitial fluids
Movement of sodium and water into interstitial fluids After the burn, in the emergent phase, the capillary walls become more permeable, causing the movement of sodium, water, and plasma proteins into the interstitial spaces and surrounding tissues. An increased excretion of urine and the return of interstitial fluid to the vascular spaces occurs toward the end of the emergent phase. During the early emergent phase, colloidal osmotic pressure is decreased with progressive protein loss from the vascular spaces.
A nurse is providing care to a patient with burn injuries. Laboratory tests indicate the patient is experiencing hypernatremia. For which clinical manifestations should the nurse monitor? Select all that apply. Seizures Paresthesia Tachycardia Muscle cramps Dried, furry tongue
Seizures Dried, furry tongue Hypernatremia is an excess amount of sodium in the body, which is seen after successful fluid resuscitation required in the treatment of a significant burn injury. The manifestations of hypernatremia include seizures and a dried, furry tongue. Paresthesia is one of the symptoms of hypokalemia. Tachycardia and muscle cramps are observed in hyponatremia.
A patient who sustained burns in a house fire develops a paralytic ileus. What does the nurse suspect to be the cause of this complication? Sepsis Enteral feedings Opioid analgesics Increased gastric acid secretion
Sepsis Paralytic ileus is caused when the burn patient experiences sepsis. Enteral feedings may cause the patient to experience diarrhea. Constipation is a side effect for opioid analgesics, which are required for pain management. Curling's ulcer occurs as a result of increased gastric acid secretion.
A patient with partial-thickness burns is being treated with zolpidem. 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. To promote sleep To reduce anxiety To promote wound healing To prevent thromboembolism To provide short-term amnesic effects
To promote sleep To reduce anxiety 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.
Which type of burn injury occurs on the layers of subcutaneous fat, muscle, or deeper structures? <p>Which type of burn injury occurs on the layers of subcutaneous fat, muscle, or deeper structures?</p> Sunburn Full thickness burn Deep partial thickness burn Superficial partial thickness burn
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 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. Tea Milkshakes Protein powder Low-protein food High-calorie food
Milkshakes Protein powder 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 a lot of 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, because the demand for protein is high to promote healing and a faster recovery.
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. Use antibiotic ointments. Wait for laboratory reports. Instill methylcellulose eye drops. Arrange for ophthalmology examination. Inform the patient that periorbital edema is serious.
Use antibiotic ointments. Instill methylcellulose eye drops. Arrange for ophthalmology examination. 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.