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7. A homebound patient is receiving intravenous (IV) an tibiotics for an infected burn site. Instructions are to use gravity to infuse 100 mL over 1 hour. How many drops per minute should the nurse administer if the tubing has a drip factor of 15?

. 100 mL 1 hour 15 gtt = 25 gtt per minute 1 hour 60 minutes 1 mL

8. A nurse is providing care for a patient with burns across 30% of the body. Which of the following observations would cause the nurse to contact the registered nurse (RN) or physician? 1. Urinary output of 50 mL in the past 2 hours 2. Patient reports pain of 6/10; oral narcotic is due in 10 minutes 3. Respiratory rate is 20 and oxygen saturation is 94% 4. Blood sugar is 175 mg/dL

. (1) is correct. Acute renal insufficiency can occur as a result of hypovolemia and decreased cardiac output. Decreased urine output should be reported. (2) The LPN can administer oral narcotics. (3) Respiratory rate is within normal limits, oxygenation is acceptable. (4) Metabolic demands are very high in patients with burns and hyperglycemia is seen due to hypermetabolism but decreased urinary output is a higher priority.

1. REVIEW QUESTIONS—TEST PREPARATION Which cause of or type of burn is commonly associated with an inhalation injury? 1. Electrical 2. Flame 3. Scald 4. Contact

. (2) is correct. A burn caused by a flame, as in a house fire, is most often associated with an inhalation injury. (1) An electrical burn is one of the most serious types of burn injury and can result in loss of limbs and internal injuries. (3) A scald is a burn from a hot liquid and is common in children under age 5 and people over age 65. (4) A contact burn results from contact with hot tar, hot metals, or hot grease; it produces a full-thickness injury on contact.

3. During morning report, a nurse is assigned a patient who is in stage III burn care. What care can the nurse anticipate providing during the shift? 1. Dressing changes 2. Débridement 3. Pain management 4. Exercises

. (4) is correct—stage III is rehabilitation, and exercises will be used to return the patient to optimum function. (1, 2, 3) are more appropriate for stages I and II.

9.A patient with full thickness burns is at risk for infection. What medications should the nurse expect to provide to this patient? Select all that apply.1. Tetanus2. Gamma globulin3. Influenza vaccination4. Pneumonia vaccination5. Hepatitis B vaccination

1 , 2

5.The nurse is discussing nutritional needs for a patient recovering from full thickness burns over 35% of the body surface area. What nutritional supplements should the nurse prepare to provide to facilitate would healing? Select all that apply.1. Zinc2. Selenium3. Vitamin C4. Vitamin A5. Glutamine

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Burn victims are being transported to the emergency department. For which patients should the nurse suspect inhalation burns? Select all that apply. 1. A 51-year-old with burns to the face and neck 2. A 60-year-old who sounds hoarse when he speaks 3. A 42-year-old who suffered electrical burns at work 4. A 14-year-old with burns across the back and buttocks 5. A 39-year-old who has third-degree burns of the left leg 6. A 4-year-old rescued from the closet of a burning house

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A patient recovering from burn injuries is experiencing intense itching. What should the nurse do to help the patient with this problem? Select all that apply.1. Massage the areas.2. Apply heat to the areas.3. Apply cold to the areas.4. Provide an oatmeal bath.5. Gently scratch the surfaces

1, 3 ,4

6. A patient has a burn encircling the left thigh from a mo torcycle accident. When the nurse enters the room dur ing rounds, the patient appears very anxious and reports a funny feeling in the left foot. What should the nurse do first? 1. Check circulatory status in the foot and report changes. 2. Explain that some numbness and tingling in the affected extremity are normal following a burn. 3. Check the burn dressing for an increase in drainage. 4. Determine the cause of the patient's anxiety.

(1) is correct—circulation is a concern with any burn, but especially with a circumferential burn. (2) Numbness and tingling are signs of circulatory impairment and are not normal and (3, 4) may be appropriate, but circulation is the first priority.

9. While caring for a 28-year-old patient newly admitted for burns received in a household fire, the nurse would be most concerned by which of the following? 1. Hematocrit = 48% 2. Blood pressure = 92/40 mm Hg 3. Pulse = 96 beats per minute 4. Respiratory rate = 22 per minute

(2) is correct. In the first 48 hours after a burn, fluid shifts lead to hypovolemia and, if untreated, hypo - volemic shock; this blood pressure is alarmingly low and should be reported. (1) Loss of intravascular fluid causes an increase in hematocrit; this reading is still within normal limits. (3) Tachycardia may be related to fluid loss, hypermetabolism, or other hematologic changes; this pulse rate is not critical. (4) Hyperventilation may occur and increased oxygen consumption due to hypermetabolism, fear, anxiety or pain may occur; this respiratory rate is not critical.

5. A home care nurse visits an 82-year-old patient. On entering the home, the nurse finds that the patient has just dropped a pot of boiling water on both legs. What action should the nurse take first? 1. Call 911. 2. Remove the clothing from the affected area. 3. Place ice on the affected area. 4. Assess the extent of the burn.

(2) is correct—clothing must be removed because it can hold heat in and continue the burning process. (1 and 4) may be appropriate after clothing has been removed and the burning process stopped. (3) ice is not appropriate, and may cause additional tissue damage.

2. Which type of burn is caused by a hot liquid? 1. Radiation 2. Contact 3. Scald 4. Chemical

(3) is correct. Hot liquids cause a scald burn. (1) Radiation burns are caused by UV light or radiation therapy; (2) contact burns are caused by hot tar, hot metals, or hot grease; (4) chemical burns are caused by contact with chemicals, usually industrial.

4. A patient is brought to the emergency department with burns over 40% of the body from an apartment fire. Which assessment should take priority? 1. Burn depth 2. Percent of body surface burned 3. Respiratory status 4. Circulatory status

(3) is correct—inhalation injury is a priority concern in a home fire. (1, 2, 4) are important once respiratory status is stabilized.

The nurse is working with a dietitian to determine the caloric needs of a patient recovering from burns over 60% of the body. What should the nurse realize as the effect of the burns on the patient's body functions? 1. The need for calories doubles.2. The need for calories decreases.3. The need for calories remains the same.4. The need for calories increases by 10%.

1. After fluid replacement, the next concern is meeting the energy needs of a patient with major burns. A major burn is the most severe stress a person can sustain. If greater than 50% of the body surface is affected by the burns, the caloric needs are doubled. If nutrients are not provided, the body breaks down muscle tissue to meet energy requirement. To ensure adequate nutrition, tube feeding through a small Silastic nasogastric feeding tube is often initiated and is preferred over intravenous (IV) nutrition if the patient can tolerate it. Caloric needs do not decrease nor stay the same. Caloric needs increase by more than 10%.

16.A patient weighing 176 pounds is prescribed a diet consisting of 1.5 grams of protein/kg of body weight to aid in burn wound healing. How many grams of protein should this patient receive each day?

120 grams First determine the patient's weight in kg by dividing 176 pounds by 2.2 = 80 kilograms. Then multiply the prescribed amount of protein by the body weight or 1.5 grams × 80 kg = 120 grams. The patient is to receive 120 grams of protein each day.

2. Which of the following actions is appropriate initial treatment of a chemical burn? 1. Lavage with water. 2. Neutralize the chemical. 3. Apply the prescribed topical agent. 4. Wrap the patient in sterile sheets.

1. Lavage with water for 20 minutes for all chemical burns, along with simultaneous removal of contaminated clothing. Neutralizing a chemical takes too much time.

A patient with partial and full thickness burns to the lower extremities is started on a rigorous exercise program 72 hours after the injuries occurred. What should the nurse explain to the patient as being the purposes of this program? Select all that apply.1. Reduce scarring2. Avoid contractures3. Promote perfusion to the areas4. Maintain proper limb positioning5. Enhance oxygenation to the tissues

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A patient is being seen in the emergency department for a partial-thickness superficial burn. What characteristics should the nurse when assessing this burn? Select all that apply.1. Pink to white skin2. Serum-filled blisters3. Bright red to pink skin4. Leathery inelastic skin texture5. Glistening, moist appearance of skin6. Sensitivity to air, temperature, and touch

2, 3 ,5 ,6

The nurse is caring for a patient brought into the emergency department after a house fire. The patient has burns covering one arm and both legs. Using the "rule of nines," what should the nurse estimate as the percentage of total body surface burned? 1. 36%2. 45%3. 54%4. 63%

2. 45% In calculating body surface area using the rule of nines, the head and neck are 9%, each arm is 9%, the front of the trunk is 18%, the back of the trunk is 18%, each lower extremity is 18%, and the perineum is 1%. A patient with burns on one arm (9%) and on both legs (36%) would have an estimated 45% of the body affected by burns.

A patient is brought to the emergency department after a house fire. The patient has extensive trunk and lower extremity burns, and is diagnosed with a deep partial thickness burn. What assessment findings does the nurse expect? 1. Snowy white, painless lesions 2. Blistered, pinkish white, painful lesions 3. Blackened, painful lesions 4. Bright red, moist lesions

2. Deep partial-thickness burns are associated with pink to light red or white skin, blisters, and pain.

6.When assessing a patient with burns on the legs, the nurse notes edema in the lower leg, pale color, limited motion, and coolness to the touch. Which nursing diagnosis would be most appropriate when planning care for this patient? 1. Impaired Gas Exchange2. Ineffective Peripheral Tissue Perfusion3. Impaired Skin Integrity due to thermal injury4. Deficient Fluid Volume due to evaporative losses from wound

2. Ineffective Peripheral Tissue Perfusion

4. Which nursing interventions are appropriate for a patient with a circumferential burn to an extremity? Select all that apply. 1. Apply compression bandages starting at the distal end of the extremity. 2. Administer analgesics if numbness or tingling occur. 3. Check neurovascular status hourly. 4. Assist with escharotomy if indicated. 5. Elevate the extremity.

3, 4, 5. Circulation must be monitored. Escharotomy may be indicated. Elevation promotes venous return.

The nurse is caring for a patient following skin grafting for full-thickness burns. Two days postoperatively, the area around the graft is red and warm, and there is a foul smell under the dressing. Which action should the nurse take? 1. Remove the dressing.2. Apply an occlusive dressing.3. Notify the registered nurse (RN) or health care provider (HCP).4. Apply an antibiotic ointment dressing.

3. Notify the registered nurse (RN) or health care provider (HCP).

3. A patient is admitted to the emergency department with flame burns to the entire chest, abdomen, back, and upper extremities. Using the Rule of Nines, what approximate percentage of burns should the nurse document? 1. 36% 2. 45% 3. 54% 4. 64%

3. The trunk is 18% front, 18% back, and each arm is 9%.

The nurse is assisting with care of a patient brought into the emergency department with burns over the face, neck, and arms. The patient also has a possible fractured femur and a cough. Which nursing action should take priority? 1. Clean the burned areas.2. Begin fluid replacement.3. Ensure airway and oxygenation.4. Stabilize the suspected fractured leg.

3.Ensure airway and oxygenation. A patient with burns on the head, neck, and arms and a cough has probably suffered an inhalation injury. Care of the inhalation injury takes priority over stabilizing the leg or debriding or cleaning the burned areas of the body. Using the ABCs or airway, breathing, circulation, the nurse should ensure an adequate airway first and then establish vascular access and begin fluid replacement. Only when the ABCs have been evaluated and treated, if necessary, should stabilization of the leg and treatment of the burn wounds be started.

5. How will the nurse know if interventions for impaired gas exchange related to smoke inhalation have been effective? 1. PaCO2 is greater than 45 mm Hg. 2. SpO2 is less than 90%. 3. pH is 7.34. 4. PaO2 is 88 mm Hg.

4. PaO2 88 mm Hg is the only normal value listed.

2.An escharotomy is being discussed to help treat a patient with a burn that encircles the chest. Why is this treatment necessary for the patient? 1. Prevents scarring2. Removes the damaged tissue3. Decreases the risk of infection4. Relieves pressure and allow normal breathing

4. Relieves pressure and allow normal breathing

A patient with extensive burns is prescribed biological dressings. What should the nurse realize are the advantages of this type of dressing? 1. They are easier to store.2. They come in many different sizes and shapes.3. They are more readily available and less costly.4. They stimulate epithelialization and wound healing.

4. They stimulate epithelialization and wound healing

The nurse finds the skin on the arms of a burn patient to be white and hard, inelastic and insensitive to pressure. The nurse anticipates providing care for which type of burn? 1. Superficial2. Full thickness3. Deep partial thickness4. Superficial partial thickness

A full thickness burn has damage to all skin layers. A superficial burn is bright red to pink, blanches to touch, has serum-filled blisters, and is moist and glistening. A deep partial thickness burn may have blisters, is pink to light red to white in color, is soft and pliable, and blanches.

14.A patient is diagnosed with a deep partial thickness burn. How should the nurse explain this burn depth to the patient? 1. First degree2. Third degree3. Fourth degree4. Second degree

Correct! What was formerly known as a second-degree burn is now known as a partial-thickness (deep) burn. It affects the epidermis and up to 7/8 of the dermis. Blisters, pink to light red to white, soft and pliable, may be present, as is blanching. Pressure may be painful from exposed nerve endings. Healing time is 14 to 21 days, and some skin grafting may be needed to decrease scarring. A first degree burn is now classified as being a superficial partial thickness burn. Third and fourth degree burns are now classified as being full thickness burns.