Care of Patients with Burns ch 28

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

40ml/hr

Eschar and other cellular debris are removed from the wound.

True of procedure for debridement

A patient has been depressed and withdrawn since her injury and has expressed that "life will never be the same." Which nursing inter- vention best promotes a positive image for this burn patient? a. Discussing the possibility of reconstructive surgery with the patient b. Allowing the patient to choose a colorful scarf to cover the burned area c. Playing cards or board games with the pa- tient d. Encouraging the patient to consider how fortunate she is to be alive

a a. Discussing the possibility of reconstructive surgery with the patient

A patient has sustained a burn to the right ankle. The physician has applied the initial dressing to the ankle, and the nurse assists the patient into bed and positions the ankle to pre- vent contracture. What is the correct position the nurse uses? a. Dorsiflexion b. Adduction c. External rotation d. Hyperextension

a a. Dorsiflexion

he nurse is educating a patient who has sus- tained burns to the dominant hand. What kind of active range of motion exercises does the nurse instruct the patient to perform? a. Exercise the hand, thumb, and fingers ev- ery hour while awake. b. Exercise the fingers and thumb at least three times a day. c. Use the hands to perform activities of daily living. d. Squeeze a soft rubber ball several times a day.

a a. Exercise the hand, thumb, and fingers ev- ery hour while awake.

The nurse is caring for a firefighter who was brought in for burns around the face and up- per chest. Airway maintenance for this patient with respiratory involvement includes what action? a. Monitoring for signs and symptoms of upper airway edema during fluid resuscita- tion b. Inserting a nasopharyngeal or oropharyn- geal airway when the patient's airway is completely obstructed c. Obtaining an order for PRN oxygen per nasal cannula d. Frequently suctioning the mouth with a Yankauer suction

a a. Monitoring for signs and symptoms of upper airway edema during fluid resuscita- tion

The nurse is caring for an African-American patient with a burn injury. The patient appears to be having severe pain and discomfort that are unrelated to the burned areas. The nurse advocates that the physician order which ad- ditional test? a. Sickle cell for trait b. Drug screen for opiate abuse c. X-rays to identify bone injuries d. ECG to identify cardiac dysrhythmias

a a. Sickle cell for trait

31. 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? (Select all that apply.) a. Redness b. Pain c. Mild edema d. Moisture e. Eschar

a, b, c a. Redness b. Pain c. Mild edema

67. The nurse is monitoring the nutritional status of a burn patient. Which indicators does the nurse use? (Select all that apply.) a. Amount of food the patient eats b. Weight to height ratio c. Serum albumin d. Amount of water the patient drinks e. Blood glucose f. Serum potassium

a, b, c, e a. Amount of food the patient eats b. Weight to height ratio c. Serum albumin e. Blood glucose

43. The nurse is caring for several patients on the burn unit. Which patients have the greatest risk for developing respiratory problems? (Se- lect all that apply.) a. Patient who was in a storage room where chemicals caught fire b. Patient who was working in an area where steam escaped from a pipe c. Patient who sustained a circumferential burn to the chest area d. Patient who was burned when a firecracker exploded prematurely e. Patient who was found unconscious in a slow-burning house fire

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

What does the process of full-thickness wound healing include? (Select all that apply.) a. Healing occurs by wound contraction. b. Eschar must be removed. c. Large blisters are protective and left undis- turbed. d. Skin grafting may be necessary. e. Fasciotomy may be needed to relieve pres- sure and allow normal blood flow.

a, b, d, e a. Healing occurs by wound contraction. b. Eschar must be removed. d. Skin grafting may be necessary. e. Fasciotomy may be needed to relieve pres- sure and allow normal blood flow.

A patient with burn injuries is being dis- charged from the hospital. What important points does the nurse include in the discharge teaching? (Select all that apply.) a. Signs and symptoms of infection b. Drug regimens and potential medication side effects c. Definition of full-thickness burns d. Correct application and care of pressure garments e. Comfort measures to reduce scarring f. Dates for follow-up appointments

a, b, d, f a. Signs and symptoms of infection b. Drug regimens and potential medication side effects d. Correct application and care of pressure garments f. Dates for follow-up appointments

24. A patient comes to the clinic to be treated for burns from a barbeque fire. Although the pa- tient does not appear to be in any respiratory distress, the nurse suspects an inhalation in- jury after observing which findings? (Select all that apply.) a. Burns to the face b. Bright cherry-red color to lips c. Singed nose hairs d. Edema of the nasal septum e. Black carbon particles around the mouth f. Sweet, sugary smell to the breath

a, c, d, e a. Burns to the face c. Singed nose hairs d. Edema of the nasal septum e. Black carbon particles around the mouth

A burn patient in the fluid resuscitation phase is experiencing dyspnea. What are the priority interventions for this patient? (Select all that apply.) a. Elevate the head of bed to 45 degrees. b. Maintain patient in the supine position. c. Notify the Rapid Response Team. d. Administer an analgesic to calm the pa- tient. e. Apply humidified oxygen.

a, c, e a. Elevate the head of bed to 45 degrees. c. Notify the Rapid Response Team. e. Apply humidified oxygen

The student nurse is preparing to assist with hydrotherapy for a burn patient. The supervis- ing nurse instructs the student to obtain the necessary equipment before beginning the procedure. What equipment does the student nurse obtain? (Select all that apply.) a. Scissors and forceps b. Hydrogen peroxide c. Mild soap or detergent d. Pressure dressings e. Washcloths and gauze sponges f. Chlorhexidine sponges

a, c, e a. Scissors and forceps c. Mild soap or detergent e. Washcloths and gauze sponges

As a result of third-spacing, during the acute phase, which electrolyte imbalances may oc- cur? (Select all that apply.) a. Hyperkalemia b. Hypokalemia c. Hypernatremia d. Hyponatremia e. Hypokalemia f. Hypercalcemia

a, d a. Hyperkalemia d. Hyponatremia

Silastic epidermis and a porous dermis made from beef collagen and shark cartilage

aArtificial ski

The physician has ordered an escharotomy for a patient because of constriction around the patient's chest. The nurse is teaching the pa- tient and family about the procedure. Which statement by the family indicates a need for additional teaching? a. "He doesn't do well under general anesthe- sia." b. "He'll be awake for the procedure." c. "He will receive medication for sedation and pain." d. "We could stay with him at the bedside during the procedure."

aa. "He doesn't do well under general anesthe- sia."

26. A patient sustained a superficial-thickness burn over a large area of the body. The patient is crying with discomfort and is very con- cerned about the long-term effects. What does the nurse tell the patient to expect? a. "Healing should occur in 3 to 6 days with no scarring or complications." b. "The pain should be less because more of the nerve endings were destroyed." c. "The wound will appear red and dry with some white areas." d. "The leathery eschar will have to be re- moved before healing can occur."

aa. "Healing should occur in 3 to 6 days with no scarring or complications.

A patient who lives in a rural community sus- tained severe burns during a house fire at 10 am. The rural EMS started a peripheral IV at 11:00 am 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? a. 6:00 pm b. 7:00 pm c. 8:00 pm d. 9:00 pm

aa. 6:00 pm

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 his neighbor and has arrived at the ED in severe discomfort. What is the priority problem for this patient at this time? a. Acute pain related to damaged or exposed nerve endings b. Decreased fluid volume related to electro- lyte imbalance c. Potential for inadequate oxygenation d. Diminished self-image related to the ap- pearance of legs

aa. Acute pain related to damaged or exposed nerve endings

The nurse is reviewing the laboratory results for several burn patients who are approximate- ly 24 to 36 hours postinjury. What laboratory results related to the fluid remobilization in these patients does the nurse expect to see? a. Anemia b. Metabolic alkalosis c. Hypernatremia d. Hyperkalemia

aa. Anemia

The nurse is applying a dressing to cover a burn on a patient's left leg. What technique does the nurse use? a. Consider the depth of the injury and amount of drainage, and work distal to proximal. b. Change the dressing every 4 hours or when the drainage leaks through the dress- ing. c. Consider the patient's mobility and the area of injury, and work proximal to distal. d. Use multiple gauze layers and roller gauze to pad and protect the joint areas.

aa. Consider the depth of the injury and amount of drainage, and work distal to proximal.

Sweat and oil glands and hair follicles

aa. Dermal appendages

16. The nurse is reviewing the hemoglobin and he- matocrit results for a patient recently admitted for a severe burn. Which result is most likely related to vascular dehydration? a. Hematocrit of 58% b. Hemoglobin of 14 g/dL c. Hematocrit of 42% d. Hemoglobin of 10 g/dL

aa. Hematocrit of 58%

12. A patient was burned on the forearm after trip- ping 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? a. Leave the blisters intact because they pro- tect the wound from infection b. Use a sterile needle to open a tiny hole in each blister to drain the fluid c. Allow blisters to increase in size; then open them to prevent immunosuppression d. Leave the blisters intact unless the pain and pressure increase

aa. Leave the blisters intact because they pro- tect the wound from infection

A patient has sustained a severe burn greater than 30% TBSA. What is the best way to assess renal function in this patient? a. Measure urine output and compare this value with fluid intake. b. Weigh the patient every day and compare that to the dry weight. c. Note the amount of edema and measure abdominal girth. d. Assist the patient with a urinal or bedpan every 2 hours.

aa. Measure urine output and compare this value with fluid intake.

The nurse is caring for a burn patient who was stabilized by and transferred from a small rural hospital. The patient develops a new com- plaint 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? a. Pulmonary fluid overload due to fluid re- suscitation b. Exposure to carbon monoxide that was undiagnosed c. Fat emboli secondary to extensive injury d. Excessive oxygen therapy at the first facil- ity

aa. Pulmonary fluid overload due to fluid re- suscitation

A patient was rescued from a burning house and treated with oxygen. Initially, the patient had audible wheezing and wheezing on aus- cultation, but after approximately 30 minutes the wheezing stopped. The patient now dem- onstrates substernal retractions and anxiety. What action does the nurse take at this time? a. Recognize an impending airway obstruc- tion and prepare for immediate intubation . b. Continue to monitor the patient's respira- tory status and initiate pulse oximetry. c. Document this finding as evidence of im- provement and continue to observe. d. Stay with and encourage the patient to re- main calm and breathe deeply.

aa. Recognize an impending airway obstruc- tion 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 knowl- edge of the pathophysiology of burns, which etiology does the nursing student select? a. Related to hypovolemia and myoglobin release b. Related to fluid overload and peripheral edema c. Related to prolonged resuscitation and hy- poxia d. Related to direct blunt trauma to the kid- neys

aa. Related to hypovolemia and myoglobin release

79. Local tissue resistance to electricity varies in different parts of the body. Which tissue has the most resistance? a. Skin epidermis b. Tendons and muscle c. Fatty tissue d. Nerve tissue and blood vessels

aa. Skin epidermis

The priority expected outcome during the resuscitation phase of a burn injury is to main- tain which factor? a. The airway b. Cardiac output c. Fluid replacement d. Patient comfort

aa. The airway

Reduces pain

b b. Anesthetic

A patient has sustained a burn which appears red and moist. The nurse gently applies pres- sure to the area to assess for what sign/symp- tom? a. Intensity of pain b. Blanching c. Pitting edema d. Fluid-filled blisters

b b. Blanching

Because of the fluid shifts in burn patients, what effects on cardiac output does the nurse expect to see? a. An initial increase, then normalized in 24 to 48 hours b. Depressed up to 36 hours after the burn c. Improved with fluid restriction d. Responsive to diuretics as evidenced by urinary output

b b. Depressed up to 36 hours after the burn

A patient in the burn intensive care unit is re- ceiving vecuronium (Norcuron). What is the priority nursing intervention for this patient? a. Have emergency intubation equipment at the bedside. b. Ensure that all the equipment alarms are on and functional. c. Closely monitor the patient's urinary out- put every hour. d. Ensure that daily drug levels and electro- lyte values are obtained.

b b. Ensure that all the equipment alarms are on and functional

Membrane obtained from an animal donor

b xenograft

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 resus- citation phase? (Select all that apply.) a Potassium level of 3.2 mEq/L b Glucose level of 180 mg/dL c Hematocrit of 49% pH of 7.20 d Sodium level of 139 mEq/L

b, c, d Glucose level of 180 mg/dL c Hematocrit of 49% pH of 7.20 d Sodium level of 139 mEq/L

30. Which criterion describes a full-thickness burn wound? (Select all that apply.) a. The wound is red and moist and blanches easily. b. There is destruction to the epidermis and dermis. c. There are no skin cells for regrowth. d. The burned tissue is avascular. e. The burn wound will not be painful.

b, c, d b. There is destruction to the epidermis and dermis. c. There are no skin cells for regrowth. d. The burned tissue is avascular.

14. The home health nurse is visiting an older cou- ple for the initial visit. In observing the house- hold, the nurse identifies several behaviors and environmental factors to address. Which iden- tified factors increase the risk for burns and/or household fires? (Select all that apply.) a. Several potholders hanging within easy reach from the stove b. Ashtray with old cigarette butts on the bedside table c. Space heater very close to the bed d. Single smoke detector in the kitchen e. Back exit hall of the house used as a stor- age space

b, c, d, e b. Ashtray with old cigarette butts on the bedside table c. Space heater very close to the bed d. Single smoke detector in the kitchen e. Back exit hall of the house used as a stor- age space

The nurse is reviewing arterial blood gas (ABG) results for a patient with 35% TBSA burn in the emergent phase: pH is 7.26; Pco2 is 36 mm Hg; and HCO3- is 19 mEq/L. What condition does the nurse suspect the patient has? a. Metabolic alkalosis . Metabolic acidosis c. Respiratory acidosis d. Respiratory alkalosis

b. Metabolic acidosis

To prevent the complication of Curling's ulcer, what does the nurse anticipate the physician will order? a. b. c. d. Nasogastric tube insertion H2 histamine blockers Abdominal assessment every 4 hours Systemic antibiotic

bH2 histamine blockers

What is the maximum temperature that the skin can tolerate without injury? a. 102° F b. 104° F c. 110° F d. 120° F

bb. 104° F

The release of myoglobin from damaged mus- cle in patients with major burns can result in which potential complication? a. Paralytic ileus b. Acute kidney injury c. Limited mobility d. Hypovolemia

bb. Acute kidney injury

29. For which patient would the rule of nines method of calculating burn size be most ap- propriate? a. Child who weighs at least 50 pounds b. Adult whose weight is proportionate to height c. Adult who weighs under 300 pounds d. Child whose weight is proportionate to height

bb. Adult whose weight is proportionate to height

During shift report, the nurse learns that a new patient was admitted for an inhalation injury. The auscultation of the lungs has revealed wheezing over the mainstream bronchi since admission. During the nurse's assessment of the patient, the wheezing sounds are absent. What does the nurse do next? a. Document these findings because they in- dicate that the patient is improving. b. Assess for respiratory distress because of potential airway obstruction. c. Obtain an order to discontinue oxygen therapy because it is no longer needed. d. Encourage use of incentive spirometry to prevent atelectasis.

bb. Assess for respiratory distress because of potential airway obstruction.

A patient is transported to the ED 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 is delegated to unlicensed assistive personnel (UAP)? a. Position the patient's head to open the air- way and assist with intubation. b. Assist the respiratory therapist to maintain a seal during bag-valve-mask ventilation. c. Prepare the intubation equipment and set up the oxygen flowmeter. d. Elevate the head of the bed to achieve a high-Fowler's position.

bb. Assist the respiratory therapist to maintain a seal during bag-valve-mask ventilation

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? a. Severe sunburn after lying in the sun for several hours b. Deep full-thickness burn from an electri- cal accident c. Partial-thickness burn from picking up a hot pan d. Deep partial-thickness burn after a motor- cycle accident

bb. Deep full-thickness burn from an electri- cal accident

33. The epidermis can grow back after a burn in- jury due to which component in this layer of skin? a. Blood vessels b. Dermal appendages c. Subcutaneous tissue d. Lymph vessels

bb. Dermal appendages

32. The nurse observes peeling of dead skin on the legs of a patient with a superficial-thickness burn wound. What is the most accurate de- scription of this assessment finding? a. Blanching b. Desquamation c. Slough d. Fluid shift

bb. Desquamation

patient was admitted to the burn unit ap- proximately 6 hours ago after being rescued from a burning building. In the ED, he report- ed a dry, irritated throat "from breathing in the fumes," but otherwise had no airway com- plaints. During the shift, the nurse notes that the patient has suddenly developed marked stridor. The nurse anticipates preparing the pa- tient for which emergency procedure? a. Bronchoscopy b. Intubation c. Needle thoracotomy d. Escharotomy

bb. Intubation

73. Which statement about the third-spacing or capillary leak syndrome in a patient with se- vere burns is accurate? a. It usually happens in the first 36 to 48 hours. b. It is a leak of plasma fluids into the inter- stitial space. c. It is present only in the burned tissues. d. It can usually be prevented with diuretics.

bb. It is a leak of plasma fluids into the inter- stitial space.

25. The nurse is caring for a burn patient who re- ceived 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? a. Output will be approximately equal to fluid intake. b. Output will be decreased compared to fluid intake. c. Urine will have a very low specific gravity and a pale-yellow color. d. Output will be managed with diuretic

bb. Output will be decreased compared to fluid intake.

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 donor site? a. Stage 1 b. Partial-thickness c. Full-thickness d. Stage 4

bb. Partial-thickness

The nurse has just received a phone report on a burn patient being transferred from the burn intensive care unit to the step-down burn unit. Which task is appropriate to delegate to unli- censed assistive personnel (UAP) in order to prepare the room? a. Place sterile sheets and a sterile pillowcase on the bed. b. Place a new disposable stethoscope in the room. c. Clear a space in the corner for the patient's flowers. d. Hang a sign on the door to prohibit entry of visitors.

bb. Place a new disposable stethoscope in the room.

What is the primary reason to avoid infection with burn injuries? a. Prevent extensive scar formation b. Prevent sepsis c. Avert worsening of pain d. Avoid fever and inflammation

bb. Prevent sepsis

27. The nurse is caring for a patient brought to the ED after bending over the engine of his car when it exploded in his face. What is the prior- ity for this patient a. Initiate fluid resuscitation b. Secure the airway c. Manage pain and discomfort d. Prevent infection

bb. Secure the airway

Which vaccine is routinely administered when a burn patient is admitted to the hospital? a. Hepatitis B b. Tetanus c. Influenza d. Pneumonia

bb. Tetanus

The nurse has just received report on a pa- tient admitted for steam inhalation burns. The patient is alert and conversant, but reports that his throat feels raw. His wife says that he sounds hoarse compared to usual. Consider- ing these findings, which order does the nurse question? a. Continuous pulse oximetry b. Vital signs and airway assessment every shift c. Intubation equipment at the bedside d. Oxygen 2 L via nasal cannula to maintain saturation of greater than 90%

bb. Vital signs and airway assessment every shift

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? a. Changed every 24 to 48 hours to prevent infection b. Worn at least 23 hours a day until the scar tissue matures c. Removed for hygiene and during sleeping d. Applied with aseptic technique

bb. Worn at least 23 hours a day until the scar tissue mature

Several patients are transported from an indus- trial fire to a local ED. Which factors increase the risk of death for these patients? (Select all that apply.) a. Male gender b. Age greater than 60 years c. Burn greater than 40% TBSA d. Presence of an inhalation injury e. Presence of contact burns

bcd b. Age greater than 60 years c. Burn greater than 40% TBSA d. Presence of an inhalation injury

Which feelings are most typically expressed by the burn patient? (Select all that apply.) a. Suspicion b. Regression c. Apathy d. Denial e. Suicidal ideations f. Anger

bdf b. Regression d. Denial f. Anger

The nurse is caring for a patient who has 30% total body surface area (TBSA) burn. During the first 12 to 36 hours, the nurse carefully monitors the patient for which status changes related to capillary leak syndrome? a Bradycardia and pitting edema b Hypertension and decreased urine output c Tachycardia and hypotension d Respiratory depression and lung crackles

c

Biologic dressing from a cadaver pro- vided by a skin bank

c allograft

A patient was admitted for burns to the up- per extremities after being trapped in a burn- ing structure. The patient is also at risk for inadequate oxygenation related to inhalation of smoke and superheated fumes. Which di- agnostic test best monitors this patient's gas exchange? a. Complete blood count b. Myoglobin level c. Carboxyhemoglobin level d. Chest x-ray

c c. Carboxyhemoglobin level

The vasodilating effects of carbon monoxide in patients with carbon monoxide poisoning cause what clinical manifestation? a. Cyanosis around the lips b. Generalized pallor c. Cherry-red skin color d. Mottled skin color

c c. Cherry-red skin color

A burn patient with which condition is most likely to have mannitol (Osmitrol) ordered as part of the drug therapy? a. Peripheral edema associated with burns on the lower extremities b. Inhalation burns around the mouth caus- ing mucosal swelling c. Electrical burn and myoglobin in the urine d. Smoke inhalation and superficial burns to the forearms

c c. Electrical burn and myoglobin in the urine

. Which statement about the resuscitation phase of a burn injury is accurate? a. It occurs in the prehospital timeframe. b. It continues for about 4 hours after the burn. c. It continues for about 48 hours after the burn. d. It continues until the patient is stable.

c c. It continues for about 48 hours after the burn.

The nurse is caring for a patient with chronic pain associated with an old burn injury. Which nonpharmacologic intervention does the nurse use to help relieve the patient's pain? a. Nitrous oxide b. Cool room temperature to reduce discom- fort c. Massaging nonburned areas d. Intravenous narcotics due to delayed tissue absorption

c c. Massaging nonburned areas

28. The nurse is caring for a patient who sustained carbon monoxide poisoning while working on his car engine in an enclosed space. What as- sessment finding does the nurse anticipate? a. Patient will be cyanotic because of hypox- ia. b. Blood gas value of Pao2 will be very low. c. Patient will report a headache. d. Patient will report a dry and irritated throa

c c. Patient will report a headache.

The nurse is caring for a burn patient about to undergo hydrotherapy. Which complementary therapies are appropriate for pain management in this patient? (Select all that apply.) a. Administration of IV opioid analgesics b. Allowing the patient to make decisions re- garding pain control c. Playing music in the background d. Use of meditative breathing e. Use of guided imagery

c, d, e c. Playing music in the background d. Use of meditative breathing e. Use of guided imagery

he family reports that the burn patient is un- able to perform self-care measures, so some- one has been "doing everything for her." The nurse finds that the patient has the knowledge and the physical capacity to independently perform self-care. What is the nurse's best re- sponse? a. "What can your family do to help you feel better and stronger?" b. "You should be doing these things for yourself to increase your self-esteem." c. "What has been happening since you were discharged from the hospital?" d. "Let's review the principles of self-care that you learned in the hospital."

cc. "What has been happening since you were discharged from the hospital?"

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? a. 18% b. 24% c. 45% d. 54%

cc. 45%

A patient was involved in a house fire and suf- fered extensive full-thickness burns. In the long-term, what issue may this patient have trouble with? a. Intolerance for vitamin C b. Metabolism of vitamin K c. Activation of vitamin D d. Absorption of vitamin A

cc. Activation of vitamin D

At what point does fluid mobilization occur in patients with burns? a. After the scar tissue is formed and fluids are no longer being lost. b. Within the first 4 hours after the burns were sustained. c. After 36 hours when the fluid is reab- sorbed from the interstitial tissue. d. Immediately after the burns occu

cc. After 36 hours when the fluid is reab- sorbed from the interstitial tissue.

Without a blood supply

cc. Avascular

35. Which type of burn destroys the sweat glands, resulting in decreased excretory ability? a. Superficial b. Partial-thickness c. Full-thickness d. Deep full-thickness

cc. Full-thickness

A patient has sustained significant burns which have created a hypermetabolic state. In plan- ning care for this patient, what does the nurse consider? a. Increased retention of sodium b. Decreased secretion of catecholamines c. Increased caloric needs d. The decrease in core temperature

cc. Increased caloric needs

What is the most essential patient data needed for calculating the fluid rates, energy require- ments, and drug doses for the burn patient? a. Age b. Previous health history c. Preburn weight d. Current weig

cc. Preburn weight

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? a. Temporary discomfort that can be treated with sips of cool fluids b. Signs and symptoms of probable carbon monoxide poisoning c. Signs indicating a pulmonary injury and possible airway obstruction d. Expected findings considering the mecha- nism of injury

cc. Signs indicating a pulmonary injury and possible airway obstruction

5. Which drug therapy reduces the risk of wound infection for burn patients? a. Large doses of oral antifungal medications every 4 hours b. Silver nitrate solution covered by dry dressings applied every 4 hours c. Silver sulfadiazine (Silvadene) on full- thickness injuries every 4 hours d. Broad-spectrum antibiotics given intrave- nously

cc. Silver sulfadiazine (Silvadene) on full- thickness injuries every 4 hours

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 nurse notes that the stool is black with a tarry appearance. What does the student nurse do next? a. Report this finding to the primary nurse or the instructor. b. Obtain a stool specimen to be sent to the laboratory for analysis. c. Test for the presence of occult blood with a hemoccult card and reagent. d. Perform a dietary assessment to determine if the stool color is related to food.

cc. Test for the presence of occult blood with a hemoccult card and reagent.

7. 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? a. To perform a daily full head-to-toe assess- ment b. To assess for nausea and vomiting related to pain medication c. To assess for a paralytic ileus secondary to reduced blood flow d. To monitor increased motility that may result in cramps and diarrhea

cc. To assess for a paralytic ileus secondary to reduced blood flow

The nurse is caring for several patients on the burn unit. Which of these patients has the most acute need for cardiac monitoring? a. Older adult woman who spilled hot water over her legs while boiling noodles b. Teenager with facial burns that occurred when he threw gasoline on a campfire c. Young woman who was struck by lightning while jogging on the beach d. Middle-aged man who fell asleep while smoking and sustained burns to the chest

cc. Young woman who was struck by lightning while jogging on the beach

Which patient has the highest risk for a fatal burn injury? a. 4-year-old child b. 32-year-old man c. 45-year-old woman d. 77-year-old man

d d. 77-year-old man

Burn crust

d d. Eschar

A patient has severe burns to the anterior sur- face 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? a. Anterior chest b. Upper arms c. Palmar surface of hands d. Eyelids

d d. Eyelids

Made up of a nylon fabric that is par- tially embedded into a silicone film

dBiobrane

A patient has sustained a relatively large burn. The nurse anticipates that the patient's nutri- tional requirements may exceed how many kcal/day? a. 1500 b. 2000 c. 3000 d. 5000

dd. 5000

34. Which type of burn wound damages the epi- dermis, dermis, fascia, and tissues? a. Superficial b. Partial thickness c. Full-thickness d. Deep full-thickness

dd. Deep full-thickness

A patient who sustained severe burns to the face with significant scarring and disfigure- ment will soon be discharged from the hospi- tal. Which intervention is best to help the pa- tient make the transition into the community? a. Discuss cosmetic surgery that could occur over the next several years. b. Focus on the positive aspects of going home and being with family. c. Teach the family to perform all aspects of care for the patient. d. Encourage visits from friends and short public appearances before discharg

dd. Encourage visits from friends and short public appearances before discharg

he nurse is interviewing and assessing an electrician who was brought to the emergency department (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 as- sess for? a. Knowledge of electrical safety b. Burn marks on the dominant hand c. Injuries based on reports of pain d. Entrance and exit wounds

dd. Entrance and exit wounds

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 associ- ated with the initial third-spacing fluid shift a. Hypercalcemia b. Hypernatremia c. Hypokalemia d. Hyperkalemia

dd. Hyperkalemia

During the early phase of a burn injury, there is a drastic increase in capillary permeability. What does this physiologic change place the patient at risk for? a. Acute kidney injury b. Fluid overload c. Increased cardiac output d. Hypovolemic shock

dd. Hypovolemic shock

What is the most effective intervention for preventing transmission of infection to a burn patient? a. Use of PPE for anyone entering the pa- tient's room b. Maintaining reverse isolation during the resuscitation phase c. Use of designated equipment for patient use d. Performing hand hygiene correctly and when appropriate

dd. Performing hand hygiene correctly and when appropriate

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 correctly weigh this patient? a. Weigh once a week after morning hygiene and compare to previous weight. b. Weigh daily at the same time of day and compare to preburn weight. c. Use a bed scale and subtract the estimated weight of linens. d. Weigh daily without dressings or splints and compare to preburn weigh

dd. Weigh daily without dressings or splints and compare to preburn weigh

Peeling of dead skin

e e. Desquamation

Cells are grown in a laboratory to pro- duce cell sheets

ee. Cultured ski

Small blisters are usually opened.

f

Sterile saline is used during débride- ment.

f

Incision through the eschar and fascia

f f. Fasciotomy

Does not develop a blood supply; it disintegrates in about 48 hours

f. Amniotic membrane

Living

g g. Viable

Made of solid silicone and plastic membranes

gSynthetic dressing

Elevated potassium levels

hh. Hyperkalemia

Decreased sodium level

i i. Hyponatremia

Elevated blood osmolarity, hemoglo- bin, and hematocrit

jj. Hemoconcentration

Fat and protein breakdown

kk. Catabolism

Includes both mechanical and enzy- matic actions.

t

Nonviable tissue is removed during hydrotherapy.

t