burns quiz

The nurse is caring for a patient with chronic pain associated with an old burn injury. Which nonpharmacologic intervention does the nurse us to help relieve the patient/s pain?

Massaging nonburned areas

A patient has sustained a severe burn greater than 30% total body surface area (TBSA). What is the best way to assess renal function in this patient?

Measure urine output and compare this value with fluid intake

What is the most effective intervention for preventing transmission of infection to a burn patient?

-performing correct, proper and consistent hand hygiene

the family reports that the burn patient is unable to perform self-care measures, so someone has been "doing everything for her". The nurse finds that the patient has the knowledge and physical capacity to independently perform self-care. What is the nurse's best response?

"Can you tell me about what's been happening since you were discharged from the hospital?"

A patient sustained a superficial thickness burn over a large area of the body. The patient is crying with discomfort and is very concerned about the long term effects. What does the nurse tell the patient to expect?

-"healing should occur in 3-6 days with no scarring or complications

An adult patient is admitted to the burn unit after being burned in a house fire. Assessment reveals burns to the entire face, back of the head, anterior torso and circumferential burns to both arms. Using the rule of nines, what is the extent of the burn injury?

-45%

Several patients are transported from an industrial fire to a local emergency department (ED). Which factors increase the risk of death for these patients? SATA

-Age greater than 60 years -Burn greater than 40% TBSA -Presence of an inhalation injury

Over a period of 4 days the patient developed an elevated temperature associated with disorientation and lethargy. Lab values include a normal platelet level. Which type of infection does the nurse suspect?

-Gram positive bacterial

Which feelings are most typically expressed by the burn patient? SATA

-Regression -Denial -Anger

Which factors in the older adult increase the risk of complications from burn injury? SATA

-Slower healing time -thinner skin -altered glucose metabolism -history of heart failure

A patient was involved in a house fire and suffered extensive full thickness burns. In the long term, what issue may this patient have trouble with?

-activation of vitamin D

The home health nurse is visiting an older couple for the initial visit. In observing the household, the nurse identifies several behaviors and environmental factors to address. Which identified factors increase the risk for burns and/or household fires?

-ashtray with old cigarette butts on the bedside table -space heater very close to bed -single smoke detector in kitchen -back exit hall of the house used as storage space

The nurse is caring for a burn patient about to undergo hydotherapy. Which complementary therapies are appropriate for pain management in this patient? SATA

-playing music in the background -using meditative breathing -using guided imagery -providing healing or therapeutic touch

The student nurse is preparing to assist with hydrotherapy for a burn patient. The supervising nurse instructs the student to obtain the necessary equipment before beginning the procedure. What equipment does the student nurse obtain? SATA

-scissors and forceps -mild soap or detergent -washcloths and gauze sponges

The nurse is caring for a patient brought to the emergency department with facial burns that occurred after the patient bent over the engine of his car. What is the priority for this patient?

-secure the airway

A patient with burn injuries is being discharged from the hospital. What important points does the nurse include in the discharge teaching? SATA

-signs and symptoms of infection -drug regimens and potential medication side effects -correct application and care of pressure garments -dates for follow-up appointments

The nurse is caring for a patient who has 30% total body surface area (TBSA) burn. During the first 12-36 hours, the nurse carefully monitors the patient for which status changes related to capillary leak syndrome?

-tachycardia and hypotension

Which vaccine is routinely administered when a burn patient is admitted to the hospital?

-tetanus

Which criteria describes a full thickness burn wound?

-there is destruction to the epidermis and dermis -there are no skin cells for regrowth -the burned tissue is avascular -the burn wound has a dry, hard, leathery eschar

The nurse is caring for a patient with 45% total body surface area (TBSA) burns. Which are priority medical surgical concepts for this patient?

-tissue integrity -perfusion -fluid and electrolyte balance

The nurse is performing a morning assessment on a patient admitted for serious burns to the extremities. For what reason does the nurse assess the patient's abdomen?

-to assess for a paralytic ileus secondary to reduced blood flow

The nurse is caring for a firefighter who was brought in for burns around the face and upper chest. Airway management for this patient with respiratory involvement includes what action?

Monitoring for signs and symptoms of upper airway edema during fluid resuscitation

A patient in the burn intensive care unit weighed 80 kg (preburn weight). The provider orders titration of IV fluid to achieve 0.5mL/kg/hr urine output. What is the minimal ourly urine output for this patient?

40 mL/hr

A patient has sustained a relatively large burn. The nurse anticipates that the patient's nutritional requirements may exceed how many kcal/day?

5000

A patient who lives in a rural community sustained severe burns during a house fire at 10 am. The rural emergency medical services (EMS) started a peripheral IV at 11:00am at a keep-vein-open (KVO) rate. The patient was admitted to the hospital at 1:00 pm. In calculating the fluid replacement , at what time is the fluid for the first 8-hour period completed?

6:00 pm

Which patient has the highest risk for a fatal burn injury?

77 year old man

At what point does fluid mobilization occur in patients with burns?

About 24 hours after the burn injury when the fluid is reabsorbed from the interstitial tissue

A 28-year-old male patient sustained second and third degree burns on his legs (30%) when his clothing caught fire while he was burning leaves. He was hosed down by a neighbor and arrived at the emergency department (ED) in severe discomfort. What is the priority problem for the patient at this time?

Acute pain related to damaged or exposed nerve endings

To prevent the complication of Curling's ulcer, what does the nurse anticipate the health care provider will order?

Histamine 2 blockers

A patient has been depressed and withdrawn since her injury and expressed that 'life will never be the same." Which nursing intervention best promotes a positive image for this burn patient?

Discussing the possibility of reconstructive surgery with the patient

The health care provider has ordered an escharotomy for a patient because of constriction around the patient's chest. The nurse is teaching the patient and family about the procedure. Which statement by the family indicates a need for additional teaching?

He will have the receive general anesthesia

What is the most essential patient data needed for calculating the fluid rates, energy requirements, and drug doses for the burn patient?

Preburn Weight

The nurse is caring for an African American patient with a brain injury. The patient is experiencing severe pain and discomfort that are unrelated to the burned areas. The nurse advocates that the provider order which additional test?

Sickle Cell for trait

Which drug therapy reduces the risk of wound infection for burn patients?

Silver sulfadiazine on full-thickness injuries every 4 hours

A patient was admitted for burns to the upper extremities after being trapped in a burning structure. The patient is also at risk for inadequate oxygenation related to inhalation of smoke and superheated fumes. Which diagnostic test best monitors the patient's gas exchange?

carboxyhemoglobin level

the vasodilating effects of carbon monoxide patients with carbon monoxide poisoning cause what clinical manifestation?

cherry-red skin color

The nurse is applying a dressing to cover a burn on a patient's left leg. What technique does the nurse use?

consider the depth of the injury and amount of drainage, and work distal to proximal

The nurse is caring for a burn patient who was stabilized by and transferred from a small rural hospital. The patient develops a new complaint of shortness of breath. On auscultation, the nurse hears crackles throughout the lung fields. What does the nurse suspect is causing this patient's symptoms?

pulmonary fluid overload due to fluid resuscitation

A patient was rescued from a burning house and treated with oxygen. Initially, the patient had audible wheezing and wheezing on auscultation, but after approximately 30 minutes the wheezing stopped. The patient now demonstrates substernal retractions anxiety. What action does the nurse take at this time?

recognize an impending airway obstruction and prepare for immediate intubation

The nursing student notes on the care plan that the burn patient she is caring for is at risk for organ ischemia. Based on the student's knowledge of the pathophysiology fo burns, which etiology does the nursing student select?

related to hypovolemia and hypotension

The nurse is caring for a firefighter who was trapped for a prolonged period of time by burning debris. During the shift, the nurse notes a progressive hoarseness, a brassy cough, and the patient reports increased difficulty with swallowing. How does the nurse interpret these changes?

signs indicating a pulmonary injury and possible airway obstruction

The student nurse is caring for a patient who has been in the burn unit for several weeks. The patient needs assistance with the bedpan to have a bowel movement, and the student notes that the stool is black with a tarry appearance. What is the most important priority action at this time?

test for the presence of occult blood with a Hemoccult card and reagent

The priority expected outcome during the resuscitation phase of a burn injury is to maintain which factor?

the airway

The nurse has just received report on a patient admitted for steam inhalation burns. The patient is alert conversant but reports that his throat feels raw. His wife says that he sounds hoarse compared to usual. Considering these findings, which order should the nurse question?

vital signs and airway assessment twice a day

A burn patient refuses to eat. The potential problem of weight loss related to increased metabolic rate and reduced calorie intake is identified for this patient. What method does the nurse use to weight this patient correctly?

weight daily without dressings or splints and compare to preburn weight

A burn patient must have pressure dressings applied to prevent contractures and reduce scarring. For maximum effectiveness, what procedure pertaining to the pressure garments is implemented?

worn at least 23 hours a day until the scar tissue matures

The nurse is caring for a several patients on the burn unit. Which of these patients has the most acute need for cardiac monitoring?

young woman who was struck by lightening while jogging on the beach

During shift report, the nurse learns that a new patient was admitted for an inhalation injury. Auscultation of the lungs has revealed wheezing over the mainstem bronchi since admission. During the nurse's assessment of the patient, the wheezing sounds are absent. What does the nurse do next?

-assess for respiratory distress because of potential airway obstruction

The nurse is providing care for a burn patient who recently received a graft. On assessment of the patient's wound, redness and swelling as well as some foul-swelling drainage is noted. What does the nurse suspect?

Local infection of burn wound

Because of the fluid shifts in burn patients, what effect on cardiac output does the nurse expect to see?

depressed up to 36 hours after the burn

A patient was admitted to the burn unit approximately 6 hours ago after being rescued from a burning building. In the emergency department, he reported a dry, irritated throat "from breathing in the fumes" but otherwise had no airway complaints. During the shift, the nurse notes that the patient has suddenly developed marked stridor. The nurse anticipates preparing the patient for which emergency procedure?

intubation

Which statement about the resuscitation phase of a burn injury is accurate?

it continues for about 24-48 hours after the burn

Which statement about the third-spacing or capillary leak syndrome in a patient with severe burns is accurate?

it is a leak of plasma fluids into the interstitial space

A patient with a burn injury had an autograft. The nurse learns in report that the donor site is on the upper thigh. What type of wound does the nurse expect to find at the donor site?

partial thickness

The nurse has just received phone report on a burn patient being transferred from the burn intensive are unit to the step-down burn unit. Which of these tasks is appropriate to delegate to unlicensed assistive personnel in order to prepare the room?

place a new disposable stethoscope in the room

The nurse is caring for a burn patient who received rigorous fluid resuscitation in the ED for hypotension and hypovolemic shock. In assessing renal function for the first 24 hours, what finding does the nurse anticipate?

-output will be decreased compared to fluid intake

For which patient would the rule of nines method of calculating burn size be most appropriate?

-adult whose weight is proportionate to height

The nurse is changing a burn patient's dressings. Which factors would affect the number of gauze layers applied after a topical agent has been used to treat the wound? SATA

-amount of drainage -patient mobility -depth of injury -frequency of dressing changes

The nurse is monitoring the nutritional status of a burn patient. Which indicators will the nurse use? SATA

-amount of food the patient eats -weight to height ratio -serum albumin -blood glucose

What is the primary reason to prevent infection with burn injuries?

-avoid sepsis

A patient has sustained a burn that appears red and moist. The nurse gently applies pressure to the area to assess for what sign/symptom?

-blanching

A patient comes to the clinic to be treated for burns from a barbecue fire. Although the patient does not appear to be in any respiratory distress, the nurse suspects an inhalation injury after observing which findings?

-burns to the face -singed nose hairs -edema of the nasal septum -black carbon particles around the mouth

Which type of burn wound damages the epidermis, dermis, fascia, and tissues?

-deep full thickness

The nurse is caring for several patients who have sustained burns. The patient with which initial injury is the least likely to experience severe pain when a sharp stimulus is applied?

-deep full thickness burn from an electrical accident

The nurse observes peeling of dead skin on the legs of a patient with superficial thickness burn wound. What is the most accurate description of this assessment finding?

-desquamation

A burn patient in the fluid resuscitation phase is experiencing dyspnea. What are the priority interventions for this patient? SATA

-elevate the head of the bed to 45 degrees -notify the rapid response team -apply humidified oxygen

The nurse is interviewing and assessing an electrician who was brought to the ED after being "electrocuted". Bystanders report that he was holding onto the electrical source "for a long time". The patient is currently alert with no respiratory distress. During the interview, what does the nurse assess for?

-entrance and exit wounds

A patient has severe burns to the anterior surface of the body from a short exposure to high temperatures at a worksite furnace. Which area of the body is most vulnerable to a deep burn injury?

-eyelids

Which type of burn destroys the sweat glands, resulting in decreased excretory ability?

-full thickness

The nurse is caring for a young woman who sustained burns on the upper extremities and anterior chest while attempting to put out a kitchen grease fire. Which laboratory results does the nurse expect to see during the resuscitation phase? SATA

-glucose level of 180 mg/dL -hematocrit of 49% -pH of 7.20 -albumin level of 2.9 g/dL

What does the process of full-thickness wound healing include? SATA

-healing occurs by wound contraction -eschar must be removed -skin grafting may be necessary -fasciotomy may be needed to relieve pressure and allow normal blood flow

The nurse is reviewing the hemoglobin and hematocrit results for a patient recently admitted for a severe burn. Which result is most likely related to vascular dehydration?

-hematocrit of 58%

The nurse is caring for several patients on the burn unit who have sustained extensive tissue damage. The nurse should monitor for which electrolyte imbalance that is typically associated with the initial third spacing fluid shift?

-hyperkalemia

As a result of third-spacing, during the acute phase, which electrolyte imbalances may occur? SATA

-hyperkalemia -hyponatremia

The nurse is caring for several patients on the burn unit. Which patients have the greatest risk for developing respiratory problems? SATA

-patient who was in a storage room where chemicals caught fire -patient who was working in an area where steam escaped from a pipe -patient who sustained a circumferential burn to the chest area -patient who was found unconscious in a slow-burning house fire

The nurse is caring for a patient who sustained carbon monoxide poisoning. What assessment finding does the nurse anticipate?

-patient will report a headache

Which are expected outcomes when evaluating the care of a patient with burn injuries? SATA

-patient's airway remained patent -patient's pain was decreased or relieved -patient's perception of self is positive

The nurse is assessing a patient with a burn wound to the back and chest area. Which assessment findings are consistent with a superficial thickness burn wound?

-pink to red -pain -mild edema -blanch to pressure

During the early phase of a burn injury, there is a drastic increase in capillary permeability. This physiologic change places the patient at risk for which problem?

-hypovolemic shock

A patient was burned on the forearm after tripping and falling against a wood burning stove. There are currently several small blisters over the burn area. What does the nurse advise the patient to do about the blisters?

-leave the blisters intact because they protect the wound from infection

The nurse is reviewing arterial blood gas (ABG) results for a patient with 35% total body surface area (TBSA) burn in the resuscitation phase: pH 7.26, PCO2 is 36 mmhg, and HCO3 is 19 mEq/L. What condition does the nurse suspect?

-metabolic acidosis

The nurse is reviewing the laboratory results for several burn patients who are approximately 24-36 hours postinjury. What laboratory results related to the fluid remobilization in these patients does the nurse expect to see?

anemia

The release of myoglobin from damaged muscle in patients with major burns can result in which potential complication?

acute kidney injury

A patient is transported to the emergency department for severe and extensive burns that occurred while he was trapped in a burning building. The patient is severely injured with respiratory distress, and the resuscitation team must immediately begin multiple interventions. Which task should be delegated to unlicensed personnel?

assist the respiratory therapist to maintain a seal during bag-valve-mask ventilation

A patient has sustained a burn to the right ankle. The health care provider applied the initial dressing to the ankle, and the nurse assists the patient into bed and positions the ankle to prevent contracture. What is the correct position the nurse uses?

dorsiflexion

A burn patient with which condition is most likely to have mannitol (Osmitrol) ordered as part of the drug therapy?

electrical burn with myogoblin in the urine

A patient who sustained severe burns to the face with significant scarring and disfigurement will soon be discharged from the hospital. Which intervention is best to help the patient make the transition into the community?

encourage visits from friends and short public appearances before discharge

A patient in the burn intensive care unit is receiving vecuronium (Norcuron). What is the priority nursing intervention for this patient?

ensure that all equipment alarms are on and functional

The nurse is educating a patient who has sustained burns to the dominant hand. What kind of active range-of-motion exercises does the nurse instruct the patient to perform?

exercise the hand, thumb, and fingers every hour while awake

A patient has sustained significant burns that have created a hypermetabolic state. In planning care for this patient, what does the nurse consider?

increased caloric needs