Burns

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? 1 Infection to the respiratory tract 2 Infection from urine contamination 3 Infection to the vascular and nerve supply 4 Infection because of poor blood supply to the cartilage

2. 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. NOT 1. A patient with burns to the face and neck is susceptible to infection of the respiratory tract 3. Burns to the hands and feet put the patient at risk for infection of the vascular and nerve supplies. 4. Infection because of poor blood supply to the cartilage is found in patients with ear and nose burns.

A patient's partial-thickness burn injuries were debrided and covered with a silver-impregnated dressing a week ago. Today the nurse notes the wounds have been fully debrided. Which would be the nurse's priority intervention for wound care at this time? 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. 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. NOT 1. 3. 4. The nurse would not wash the wound aggressively with saline three times daily, apply cool compresses, or apply a new dressing at this time.

A nurse working in a burn unit would identify which patients are at an increased risk of developing venous thromboembolism? Select all that apply. 1 Young age 2 Morbid obesity 3 Prolonged immobility 4 Upper-extremity burns 5 First-degree burn of a finger

2.3. The risk factors for the development of VTE in a burn patient are morbid obesity and prolonged immobility. These patients may develop stasis of blood due to immobility, which results in development of VTE NOT 1. not a risk factor for VTE; rather, old age predisposes a person to VTE 4. Usually, lower-extremity burns are risk factors for VTE because they cause stagnation of blood 5. not an extensive burn and hence is not a risk factor for VTE.

Which clinical manifestations would the nurse observe in a patient during the emergent phase of a burn injury? Select all that apply. 1 Increased appetite 2 Increased heart rate 3 Increased urine output 4 Decreased respiratory rate 5 Decreased BP

2. 5. During the emergent phase of a burn injury, the patient exhibits tachycardia and hypotension NOT 1. loss of appetite 3. decreased urine output 4. tachypnea

Which patients are appropriate for the nurse to refer to the burn center? Select all that apply. 1 A patient with burns of the feet 2 A patient with an inhalation injury 3 An elderly patient with third-degree burns 4 A patient with burns involving minor joints 5 A patient with partial-thickness burns involving 8% of total body surface area

2. A burn care unit provides advanced care to burn patients to prevent complications and keep the condition from worsening. An inhalation injury increases the risk of airway obstruction and requires a referral to the burn unit. 1. Burns on both feet are associated with complications like contractures, and the patient needs to be referred to the burn care unit. 3. Third-degree burns in any age-group require referral. NOT 4. Burns involving minor joints do not require referral to burn centers; however, burns of major joints require referral. 5. Partial-thickness burns require referral if they involve more than 10% of the body surface area

A patient with partial-thickness burns is being treated with zolpidem, and the family inquires why the patient is receiving the medication. Which responses by the nurse are appropriate? Select all that apply. 1 "It is used to help promote sleep." 2 "It is used to reduce anxiety." 3 "It is used to promote wound healing." 4 "It is used to prevent thromboembolism." 5 "It is used to provide short-term amnesic effects."

1. 2. 5. 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. NOT 3. Nutritional support is used to promote wound healing. 4. Anticoagulants are used to prevent thromboembolism.

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. 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. NOT 2. Redness and pain with minimal damage to the epidermis are characteristics of a superficial, or first-degree, burn. 3.4. Necrosis and charring are seen with a full-thickness burn.

Which type of burn injury would the nurse identify as occurring 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. A full-thickness burn is a burn of the layers of subcutaneous fat, muscle, or deeper structures. NOT 1.4. A superficial partial-thickness burn is a burn of the epidermis layer; a sunburn is a type of superficial partial-thickness burn 3. A deep partial-thickness burn involves the dermis layer between the epidermis and subcutaneous layers.

Which patient signs and symptoms noted during triage would indicate to the nurse an upper airway injury? Select all that apply. 1 Dyspnea 2 Hoarseness 3 Difficulty swallowing 4 Copious secretions 5 Carbonaceous sputum

2. An inhalation injury in the upper airway involves the mouth, oropharynx, and/or larynx. It may cause hoarseness in the voice because of the effect on the larynx. 3. There may be difficulty in swallowing because of the involvement of the mouth and oropharynx. 4. There may be copious secretions in response to the injury to the airway. NOT 1.5. The injury to the lower airway involves the trachea, bronchioles, and alveoli and may cause carbonaceous sputum and dyspnea.

When caring for a patient with an electrical burn injury, which prescription from the health care provider would the nurse question? 1 Urine for myoglobin 2 Lactated Ringer's at 25 mL/hr 3 Mannitol 75 gm IV 4 Sodium bicarbonate 24 mEq every 4 four hours

2. Electrical injury puts the patient at risk for myoglobinuria, which can lead to acute tubular necrosis (ATN). Treatment consists of infusing lactated Ringer's at 2 to 4 mL/kg/% total body surface area (TBSA), a rate sufficient to maintain urinary output at 75 to 100 mL/hr. An infusion rate of 25 mL/hr is not sufficient to maintain adequate urine output in the prevention and treatment of ATN. NOT 3. Mannitol also can be used to maintain urine output. 1. The urine would also be monitored for the presence of myoglobin 4. Sodium bicarbonate may be given to alkalinize the urine.

A patient with burns needs permanent skin grafting. Which types of grafts would the nurse expect to be considered? Select all that apply. 1 Integra 2 AlloDerm 3 Autograft 4 Homograft 5 Heterograft

1. Integra is obtained from bovine collagen and glycosaminoglycan bonded to silicone and gives permanent coverage 2. AlloDerm is obtained from a cellular dermal matrix derived from donated human skin and can be used for permanent grafting 3. Autograft is from the patient's own skin and can be used for permanent grafting. NOT 4. Homograft is obtained from cadaveric skin and can be used as a temporary graft from three days to two weeks. 5. Heterograft is obtained from porcine skin and can be used as a temporary graft from three days to two weeks.

Which intervention would the nurse provide when caring for a patient with a burn injury during the acute phase? 1 Provide teaching about the physical aspects of recovery. 2 Discuss the possible need for home care nursing. 3 Discuss the need for reconstructive surgery. 4 Begin IV fluid replacement.

1. Nurses should provide ongoing support, counseling, and teaching to the patient and the caregiver regarding the physical and emotional aspects of care and recovery. NOT 2.3. Discussing the need for both home care following discharge and the need for reconstructive surgery occurs during the rehabilitation phase. 4. Beginning fluid replacement occurs in the emergent phase.

When planning for burn management, which patients would 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 suffering from hydrochloric acid burns, also known as chemical burns, should be referred to a burn center. 3. Patients of all ages with third-degree burns are severe in condition and should be treated in a burn center 4. All patients with partial-thickness burns of more than 10% of body surface area should be referred to a burn center because they are severe types of burns and need specialized treatment, care, and isolation NOT 2. Patients of all ages with first-degree burns can be managed in the hospital and assessed. 5. Patients with 5% superficial partial-thickness burns need not necessarily be referred and can be managed in the hospital.

A nurse is assessing a patient who was burned after contact with gasoline. Which complication would the nurse monitor? 1 Melting 2 Systemic toxicity 3 Protein hydrolysis 4 Severe metabolic acidosis

2. Gasoline is an organic compound that causes chemical burns. This compound produces systemic toxicity in patients NOT 1. 3. Liquefaction and protein hydrolysis occur due to chemical burns resulting from alkalis. 4. Electrical injury results in severe metabolic acidosis.

A nurse is instructing a patient about the immediate steps that need to be taken in the case of electrical burns. Which precautions would the nurse instruct as necessary to perform? Select all that apply. 1 Do not cover the burned part with ice. 2 Do not remove any burned clothing from the body. 3 Do not immerse the burned part in cool water. 4 Cool large burns for not more than 10 minutes. 5 Apply ice to the burned part as early as possible

1. The burned body part of a person suffering from an electrical injury should not be covered with ice because it can cause hypothermia and vasoconstriction and can significantly reduce the blood flow to the affected area. 3. Do not immerse the burned part in cold water because it may cause extensive heat loss 4. Cooling burns for more than 10 minutes can cause hypothermia NOT 5. Applying ice to the burned part can cause hypothermia. 2. Burned clothes can be removed gently to avoid further tissue damage; however, clothes that are adhered to the body should not be removed.

While caring for a patient with burns, a nurse wraps the patient's wound with tubular elastic gauze. Which are the reasons behind this action? Select all that apply. 1 To decrease pain 2 To prevent blistering 3 To decrease itchiness 4 To reduce venous return 5 To enhance local immunity

1.2.3. The interim pressure from tubular elastic gauze decreases pain and itchiness and prevents blistering. NOT 4. It promotes venous return rather than reducing it. 5. It does not enhance local immunity.

Which nursing interventions are appropriate for providing enteral feeding to a patient who is intubated and has burns of more than 5% of the total body surface area (TBSA)? Select all that apply. 1 Check gastric residuals frequently. 2 Assess bowel sounds every eight hours. 3 Determine whether the nasogastric tube is in place. 4 Begin the feedings slowly at the rate of 10 to 20 mL/hr. 5 Increase the feeding to the goal rate within 24 to 48 hours.

1.2.3.5. A patient who is intubated and has suffered burns to more than 5% of the TBSA may need gastric feedings to meet adequate nutritional requirements. Early enteral feeding helps to preserve gastrointestinal function, increase intestinal blood flow, and promote optimal conditions for wound healing. The nurse should check the placement of the nasogastric tube and assess bowel sounds every eight hours. NOT 4. The enteral feedings should be started at 20 to 40 mL/hr and slowly increased to the goal rate within 24 to 48 hours. Gastric residuals should be checked to rule out delayed gastric emptying.

Which pathophysiologic changes would the nurse anticipate while caring for a burn patient? Select all that apply. 1 Increased viscosity 2 Decreased hematocrit 3 Decreased blood volume 4 Increased vascular permeability 5 Decreased peripheral resistance

1.3.4. In a burn injury, the viscosity of body fluids is increased, the blood volume is reduced, and vascular permeability is increased NOT 2. 5. The hemoconcentration that accompanies burn shock can result in hematocrits as high as 70%. This increases blood viscosity, producing sludging and contributing to increased vascular resistance.

Which cardiac parameters would the nurse assess to determine the adequacy of fluid resuscitation in a patient who has sustained burns? Select all that apply. 1 Heart rate less than 120 beats/minute 2 Manual systolic BP greater than 90 mm Hg 3 Arterial line systolic BP greater than 90 mm Hg 4 Manual mean arterial pressure greater than 65 mm Hg 5 Arterial line mean arterial pressure greater than 65 mm Hg

1.3.5. The cardiac parameters that help to assess the adequacy of fluid resuscitation are heart rate less than 120 beats/minute, arterial line systolic BP greater than 90 mm Hg, and arterial line mean arterial pressure greater than 65 mm Hg. NOT 2.4. Manual BP and manual mean arterial BP are invalid in burns because of edema and vasoconstriction.

When assessing a patient suffering from inhalation burns on the face and chest, which findings would the 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

1 due to irritation of the upper airway during inhalation and the laryngeal edema caused by inhalation injury 4.5. 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 NOT 2. Location of contact points is done in case of electrical burns. 3. skin may appear leathery, white, and charred

A patient has sustained thermal injuries amounting to approximately 30% of the total body surface area (TBSA). Which action would the nurse take first? 1 Cover the burned body area with ice. 2 Immerse the burned body area in cool water. 3 Check for a patent airway, breathing, and circulation. 4 Cover the burned area with a clean, cool, tap water-dampened towel.

3. 1st step in the management of a person who has sustained thermal injuries on 10% or more of body surface is to assess ABCs. If injury less than 10% of TBSA, it would be appropriate to cover burned area with a clean, cool, damp towel, only after the checking ABCs NOT 1. not appropriate to cover with ice because it can cause hypothermia and vasoconstriction = further reduce the blood flow to the injury site 2.4. Immersing the patient or the patient's afflicted area in cool water may cause extensive heat loss.

Which treatment would the nurse recognize as appropriate and within the scope of nursing practice when caring for a patient with partial-thickness second-degree burns to the chest, abdomen, and both anterior thighs? 1 Application of autografts and daily sterile dressing changes 2 Twice-weekly wound cleaning and sterile dressing changes 3 Daily wound cleaning with debridement and sterile dressing changes 4 Daily wound cleaning with hydrotherapy and clean dressing changes

3. Daily wound cleansing with debridement and sterile dressing changes is appropriate care for a major burn wound. As a means of promoting healing and preventing infection, wound care and dressing changes are performed once or twice a day with a sterile procedure. NOT 1.2.4. The other answer options are not within the scope of nursing practice and may not be appropriate treatment for the burn injury sustained.

Which burn injury would the nurse identify as resulting in tissue anoxia? 1 Thermal burn 2 Chemical burn 3 Electrical injury 4 Inhalational injury

3. Electrical injury causes tissue anoxia due to nerve damage and nerve death. NOT 1. The injury sustained by a thermal burn is dependent on the temperature of the burning agent and the length of exposure. 2. Chemical burns can cause tissue damage, and eyes can be injured if a splash occurs 4. Smoke and inhalation injury result in hypoxia.

While planning physical therapy for a patient suffering from burns, which intervention would the nurse include in the plan of care? Select all that apply. 1 Perform exercises before wound cleansing. 2 Practice physical therapy only occasionally. 3 Perform passive and active range of motion (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 to avoid contractures and prevent compromising the patient's cardiopulmonary status. 5. A good time for exercise is during and after wound cleansing, when the skin is softer and bulky dressings are removed. NOT 2. not a good habit to practice PT only occasionally. This is because continuous PT throughout burn recovery is imperative if the patient needs to regain and maintain muscle strength and optimal joint function 1. Performing exercises before wound cleansing is not appropriate. 4. 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.

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? 1 Serum sodium and potassium increase 2 Serum sodium and potassium decrease 3 Edema and arterial blood gases improve 4 Diuresis occurs and hematocrit decreases

4. In the emergent phase, the immediate, life-threatening problems from the burn—hypovolemic shock and edema—are treated and resolved. Toward the end of the emergent phase, fluid loss and edema formation end. Interstitial fluid returns to the vascular space and diuresis occurs. Urinary output is the most commonly used parameter to assess the adequacy of fluid resuscitation. The hemolysis of red blood cells (RBCs) and thrombosis of burned capillaries also decreases circulating RBCs. When the fluid balance has been restored, dilution causes the hematocrit levels to drop. NOT 1.2. Initially Na moves to the interstitial spaces and remains there until edema formation ceases, so Na increase at the end of the emergent phase as the Na moves back to the vasculature. Initially, K increases as it is released from injured cells and hemolyzed RBCs, so K decrease at the end of the emergent phase when fluid levels normalize. 3. Changes in arterial blood gases do not readily identify stage of burn injury.

A nurse is providing care to a patient with a partial-thickness burn. Which clinical manifestation would the nurse anticipate? 1 Coagulation necrosis 2 Damage to all skin elements 3 Destruction of all nerve endings 4 Damage to epidermis and dermis involving varying depths

4. Partial-thickness burns involve damage to the epidermis and dermis at varying depths. NOT 1. 2. 3. Coagulation necrosis, damage to all skin elements, and the destruction of nerve endings are observed in full-thickness burn injuries.

Which clinical manifestation would the nurse anticipate due to thrombosis in the capillaries of the burned tissue of a patient? 1 Elevated heart rate 2 Elevated hematocrit 3 Decreased BP 4 Decreased erythrocyte count

4. Thrombosis in the capillaries of burned tissue results in a loss of circulating erythrocytes (red blood cells). NOT 1. 3. An elevated HR and decreased BP are signs of hypovolemic shock, which is caused by a massive shift of fluids out of the blood vessels 2. Hematocrit is elevated in burn injuries due to the hemoconcentration that results from fluid loss (NOT thrombosis in the capillaries of the burned tissue).

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. 1 Movement of potassium into the cells 2 Adherence of albumin to vascular walls 3 Edema in nonburned areas (third spacing) 4 Elevated hematocrit caused by hemoconcentration 5 Movement of water and sodium to the interstitial fluid

5. During the emergent phase, sodium and water rapidly shift to the interstitial spaces and remain there until edema formation ceases. 4. hematocrit is elevated because of hemoconcentration related to fluid loss (fluid exeting vascular space) 3. Fluid also moves to areas that normally have minimal to no fluid, a phenomenon termed third spacing. NOT 1. potassium shift initially develops because injured cells and hemolyzed red blood cells release potassium into the circulation 2. Albumin also shifts into the interstitial spaces, contributing to the edema

tissue anoxia

A condition in which there is an absence of oxygen supply to an organ's tissues although there is adequate blood flow to the tissue. Hypoxia is a condition in which there is a decrease of oxygen to the tissue in spite of (even though) adequate blood flow to the tissue.

Full-thickness scald injury

A full-thickness scald (hot water) injury is characterized by redness and edema at the affected site. It is caused by immersion of the body part in hot water.

Full-thickness thermal burn

A full-thickness thermal burn appears as dry, leathery eschar with a waxy white, dark-brown, or charred appearance. (burnt hand picture)

Chemical burn

Chemical burn injuries involve discoloration and damage of injured tissue.

Electrical burn

Electrical burn injuries are characterized by coagulation spots on the contact areas of burns.

deep partial-thickness burn vs full-thickness burns

In a deep partial-thickness burn, the structures involved are the epidermis and dermis to varying depths. It is known as a second-degree burn. Fat, muscle and bone are structures involved in full-thickness burns, which are third- and fourth-degree burns.

Thrombosis

local coagulation or clotting of the blood in a part of the circulatory system.