COMPLEX QUIZ #3

A nurse administers topical gentamicin sulfate (Garamycin) to a client's burn injury. Which laboratory value should the nurse monitor while the client is prescribed this therapy? a. Creatinine b. Red blood cells c. Sodium d. Magnesium

ANS: A Gentamicin is nephrotoxic, and sufficient amounts can be absorbed through burn wounds to affect kidney function. Any client receiving gentamicin by any route should have kidney function monitored. Topical gentamicin will not affect the red blood cell count or the sodium or magnesium levels.

A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take? a. Notify the health care provider. b. Monitor the pulses every 2 hours. c. Elevate both legs above heart level with pillows. d. Encourage the patient to flex and extend the toes on both feet.

ANS: A The decrease in pulse in a patient with circumferential burns indicates decreased circulation to the legs and the need for an escharotomy. Monitoring the pulses is not an adequate response to the decrease in circulation. Elevating the legs or increasing toe movement will not improve the patient's circulation

Which patient should the nurse assess first? a. A patient with smoke inhalation who has wheezes and altered mental status b. A patient with full-thickness leg burns who has a dressing change scheduled c. A patient with abdominal burns who is complaining of level 8 (0 to 10 scale) pain d. A patient with 40% total body surface area (TBSA) burns who is receiving IV fluids at 500 mL/hour

ANS: A This patient has evidence of lower airway injury and hypoxemia and should be assessed immediately to determine the need for oxygen or intubation. The other patients should also be assessed as rapidly as possible, but they do not have evidence of life-threatening complications.

A nurse cares for a client with burn injuries during the resuscitation phase. Which actions are priorities during this phase? (Select all that apply.) a. Administer analgesics. b. Prevent wound infections. c. Provide fluid replacement. d. Decrease core temperature. e. Initiate physical therapy.

ANS: A, B, C Nursing priorities during the resuscitation phase include securing the airway, supporting circulation and organ perfusion by fluid replacement, keeping the client comfortable with analgesics, preventing infection through careful wound care, maintaining body temperature, and providing emotional support. Physical therapy is inappropriate during the resuscitation phase but may be initiated after the client has been stabilized.

A nurse assesses a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which assessment finding should alert the nurse to a potential complication? a. Partial pressure of arterial oxygen (PaO2) of 80 mm Hg b. Urine output of 20 mL/hr c. Productive cough with white pulmonary secretions d. Core temperature of 100.6° F (38° C)

ANS: B A significant loss of fluid occurs with burn injuries, and fluids must be replaced to maintain hemodynamics. If fluid replacement is not adequate, the client may become hypotensive and have decreased perfusion of organs, including the brain and kidneys. A low urine output is an indication of poor kidney perfusion. The other manifestations are not complications of burn injuries.

A nurse cares for a client with burn injuries from a house fire. The client is not consistently oriented and reports a headache. Which action should the nurse take? a. Increase the client's oxygen and obtain blood gases. b. Draw blood for a carboxyhemoglobin level. c. Increase the client's intravenous fluid rate. d. Perform a thorough Mini-Mental State Examination.

ANS: B These manifestations are consistent with moderated carbon monoxide poisoning. This client is at risk for carbon monoxide poisoning because he or she was in a fire in an enclosed space. The other options will not provide information related to carbon monoxide poisoning.

The nurse is reviewing laboratory results on a patient who had a large burn 48 hours ago. Which result requires priority action by the nurse? a. Hematocrit 53% b. Serum sodium 147 mEq/L c. Serum potassium 6.1 mEq/L d. Blood urea nitrogen 37 mg/dL

ANS: C Hyperkalemia can lead to fatal dysrhythmias and indicates that the patient requires cardiac monitoring and immediate treatment to lower the potassium level. The other laboratory values are also abnormal and require changes in treatment, but they are not as immediately life threatening as the elevated potassium level

The nurse is reviewing the medication administration record (MAR) on a patient with partial-thickness burns. Which medication is best for the nurse to administer before scheduled wound debridement? a. Ketorolac (Toradol) b. Lorazepam (Ativan) c. Gabapentin (Neurontin) d. Hydromorphone (Dilaudid)

ANS: D Opioid pain medications are the best choice for pain control. The other medications are used as adjuvants to enhance the effects of opioids.

The nurse is caring for a patient with partial- and full-thickness burns to 65% of the body. When planning nutritional interventions for this patient, what dietary choices should the nurse implement? a. full liquids only b. whatever the patient requests c. high-protein and low sodium foods d. high calorie and high protein foods

Answer: D Rationale: A hypermetabolic state occurs proportional to the size of the burn area. Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. Caloric needs are often in the 5000-kcal range. Failure to supply adequate calories and protein leads to malnutrition and delayed healing.

A patient arrives in the emergency department after being burned in a house fire. The patient's burns cover the face and the left forearm. What percentage of burn does the patient have? A) 10% B) 25% C) 9% D) 18%

Answer: D Rationale: When estimating the percentage of body area or burn surface area that has been burned, the Rule of Nines is used: the face is 9%, and the forearm is 9% for a total of 18% in this patient.

The injury that is least likely to result in a full-thickness burn is: a. sunburn b. scald injury c. chemical burn d. electrical injury

Correct answer: a Rationale: Full-thickness burns may be caused by contact with flames, scalding liquids, chemicals, tar, or electrical current.

A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain adequate nutrition, the nurse should plan to take which action? a. Insert a feeding tube and initiate enteral feedings. b. Infuse total parenteral nutrition via a central catheter. c. Encourage an oral intake of at least 5000 kcal per day. d. Administer multiple vitamins and minerals in the IV solution.

ANS: A Enteral feedings can usually be initiated during the emergent phase at low rates and increased over 24 to 48 hours to the goal rate. During the emergent phase, the patient will be unable to eat enough calories to meet nutritional needs and may have a paralytic ileus that prevents adequate nutrient absorption. Vitamins and minerals may be administered during the emergent phase, but these will not assist in meeting the patient's caloric needs. Parenteral nutrition increases the infection risk, does not help preserve gastrointestinal function, and is not routinely used in burn patients.

The charge nurse observes the following actions being taken by a new nurse on the burn unit. Which action by the new nurse would require an intervention by the charge nurse? a. The new nurse uses clean latex gloves when applying antibacterial cream to a burn wound. b. The new nurse obtains burn cultures when the patient has a temperature of 95.2° F (35.1° C). c. The new nurse administers PRN fentanyl (Sublimaze) IV to a patient 5 minutes before a dressing change. d. The new nurse calls the health care provider for a possible insulin order when a nondiabetic patient's serum glucose is elevated.

ANS: A Sterile gloves should be worn when applying medications or dressings to a burn. Hypothermia is an indicator of possible sepsis, and cultures are appropriate. Nondiabetic patients may require insulin because stress and high calorie intake may lead to temporary hyperglycemia. Fentanyl peaks 5 minutes after IV administration, and should be used just before and during dressing changes for pain management

The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine output has dramatically increased. Which action by the nurse would best ensure adequate kidney function? a. Continue to monitor the urine output. b. Monitor for increased white blood cells (WBCs). c. Assess that blisters and edema have subsided. d. Prepare the patient for discharge from the burn unit.

ANS: A The patient's urine output indicates that the patient is entering the acute phase of the burn injury and moving on from the emergent stage. At the end of the emergent phase, capillary permeability normalizes and the patient begins to diurese large amounts of urine with a low specific gravity. Although this may occur at about 48 hours, it may be longer in some patients. Blisters and edema begin to resolve, but this process requires more time. White blood cells may increase or decrease, based on the patient's immune status and any infectious processes. The WBC count does not indicate kidney function. The patient will likely remain in the burn unit during the acute stage of burn injury

An employee spills industrial acids on both arms and legs at work. What is the priority action that the occupational health nurse at the facility should take? a. Remove nonadherent clothing and watch. b. Apply an alkaline solution to the affected area. c. Place cool compresses on the area of exposure. d. Cover the affected area with dry, sterile dressings.

ANS: A With chemical burns, the initial action is to remove the chemical from contact with the skin as quickly as possible. Remove nonadherent clothing, shoes, watches, jewelry, glasses, or contact lenses (if face was exposed). Flush chemical from wound and surrounding area with copious amounts of saline solution or water. Covering the affected area or placing cool compresses on the area will leave the chemical in contact with the skin. Application of an alkaline solution is not recommended.

A nurse plans care for a client with burn injuries. Which interventions should the nurse implement to prevent infection in the client? (Select all that apply.) a. Ask all family members and visitors to perform hand hygiene before touching the client. b. Carefully monitor burn wounds when providing each dressing change. c. Clean equipment with alcohol between uses with each client on the unit. d. Allow family members to only bring the client plants from the hospital's gift shop. e. Use aseptic technique and wear gloves when performing wound care.

ANS: A, B, E To prevent infection in a client with burn injuries the nurse should ensure everyone performs hand hygiene, monitor wounds for signs of infection, and use aseptic technique, including wearing gloves when performing wound care. The client should have disposable equipment that is not shared with another client, and plants should not be allowed in the client's room.

A nurse cares for an older client with burn injuries. Which age-related changes are paired appropriately with their complications from the burn injuries? (Select all that apply.) a. Slower healing time - Increased risk for loss of function from contracture formation b. Reduced inflammatory response - Deep partial-thickness wound with minimal exposure c. Reduced thoracic compliance - Increased risk for atelectasis d. High incidence of cardiac impairments - Increased risk for acute kidney injury e. Thinner skin - May not exhibit a fever when infection is present

ANS: A, C, D Slower healing time will place the older adult client at risk for loss of function from contracture formation due to the length of time needed for the client to heal. A pre-existing cardiac impairment increases risk for acute kidney injury from decreased renal blood flow, and reduced thoracic compliance places the client at risk for atelectasis. Reduced inflammatory response places the client at risk for infection without a normal response, including fever. Clients with thinned skin are at greater risk for deeper wounds from minimal exposure.

The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by autocontamination? a. Use a disposable blood pressure cuff to avoid sharing with other clients. b. Change gloves between wound care on different parts of the client's body. c. Use the closed method of burn wound management for all wound care. d. Advocate for proper and consistent handwashing by all members of the staff.

ANS: B Autocontamination is the transfer of microorganisms from one area to another area of the same client's body, causing infection of a previously uninfected area. Although all techniques listed can help reduce the risk for infection, only changing gloves between performing wound care on different parts of the client's body can prevent autocontamination.

Which nursing action is a priority for a patient who has suffered a burn injury while working on an electrical power line? a. Obtain the blood pressure. b. Stabilize the cervical spine. c. Assess for the contact points. d. Check alertness and orientation.

ANS: B Cervical spine injuries are commonly associated with electrical burns. Therefore stabilization of the cervical spine takes precedence after airway management. The other actions are also included in the emergent care after electrical burns, but the most important action is to avoid spinal cord injury.

On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 104.1° F (40.1° C), pulse 132 beats/min, respirations 26 breaths/min, blood pressure 106/66 mm Hg. Which action should the nurse take? a. Encourage the client to drink cool water or sports drinks. b. Start an intravenous line and infuse 0.9% saline solution. c. Administer acetaminophen (Tylenol) 650 mg orally. d. Encourage rest and re-assess in 15 minutes.

ANS: B The client demonstrates signs of heat stroke. This is a medical emergency and priority care includes oxygen therapy, IV infusion with 0.9% saline solution, insertion of a urinary catheter, and aggressive interventions to cool the client, including external cooling and internal cooling methods. Oral hydration would not be appropriate for a client who has symptoms of heat stroke because oral fluids would not provide necessary rapid rehydration, and the confused client would be at risk for aspiration. Acetaminophen would not decrease this client's temperature or improve the client's symptoms. The client needs immediate medical treatment; therefore, rest and re-assessing in 15 minutes is inappropriate.

A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take? a. Encourage the patient to cough and auscultate the lungs again. b. Notify the health care provider and prepare for endotracheal intubation. c. Document the results and continue to monitor the patient's respiratory rate. d. Reposition the patient in high-Fowler's position and reassess breath sounds.

ANS: B The patient's history and clinical manifestations suggest airway edema and the health care provider should be notified immediately, so that intubation can be done rapidly. Placing the patient in a more upright position or having the patient cough will not address the problem of airway edema. Continuing to monitor is inappropriate because immediate action should occur

A nurse receives new prescriptions for a client with severe burn injuries who is receiving fluid resuscitation per the Parkland formula. The client's urine output continues to range from 0.2 to 0.25 mL/kg/hr. Which prescription should the nurse question? a. Increase intravenous fluids by 100 mL/hr. b. Administer furosemide (Lasix) 40 mg IV push. c. Continue to monitor urine output hourly. d. Draw blood for serum electrolytes STAT.

ANS: B The plan of care for a client with a burn includes fluid and electrolyte resuscitation. Furosemide would be inappropriate to administer. Postburn fluid needs are calculated initially by using a standardized formula such as the Parkland formula. However, needs vary among clients, and the final fluid volume needed is adjusted to maintain hourly urine output at 0.5 mL/kg/hr. Based on this client's inadequate urine output, fluids need to be increased, urine output needs to be monitored hourly, and electrolytes should be evaluated to ensure appropriate fluids are being infused.

A young adult patient who is in the rehabilitation phase 6 months after a severe face and neck burn tells the nurse, "I'm sorry that I'm still alive. My life will never be normal again." Which response by the nurse is best? a. "Most people recover after a burn and feel satisfied with their lives." b. "It's true that your life may be different. What concerns you the most?" c. "It is really too early to know how much your life will be changed by the burn." d. "Why do you feel that way? You will be able to adapt as your recovery progresses."

ANS: B This response acknowledges the patient's feelings and asks for more assessment data that will help in developing an appropriate plan of care to assist the patient with the emotional response to the burn injury. The other statements are accurate, but do not acknowledge the anxiety and depression that the patient is expressing.

While the patient's full-thickness burn wounds to the face are exposed, what is the best nursing action to prevent cross contamination? a. Use sterile gloves when removing old dressings. b. Wear gowns, caps, masks, and gloves during all care of the patient. c. Administer IV antibiotics to prevent bacterial colonization of wounds. d. Turn the room temperature up to at least 70° F (20° C) during dressing changes.

ANS: B Use of gowns, caps, masks, and gloves during all patient care will decrease the possibility of wound contamination for a patient whose burns are not covered. When removing contaminated dressings and washing the dirty wound, use nonsterile, disposable gloves. The room temperature should be kept at approximately 85° F for patients with open burn wounds to prevent shivering. Systemic antibiotics are not well absorbed into deep burns because of the lack of circulation.

When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the skin is dry, pale, hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth? a. First-degree skin destruction b. Full-thickness skin destruction c. Deep partial-thickness skin destruction d. Superficial partial-thickness skin destruction

ANS: B With full-thickness skin destruction, the appearance is pale and dry or leathery and the area is painless because of the associated nerve destruction. Erythema, swelling, and blisters point to a deep partial-thickness burn. With superficial partial-thickness burns, the area is red, but no blisters are present. First-degree burns exhibit erythema, blanching, and pain

A nurse uses the rule of nines to assess a client with burn injuries to the entire back region and left arm. How should the nurse document the percentage of the client's body that sustained burns? a. 9% b. 18% c. 27% d. 36%

ANS: C According to the rule of nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the client received burns to the back (18%) and one arm (9%), totaling 27% of the body.

A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first? a. Assess oral temperature. b. Check a potassium level. c. Place on cardiac monitor. d. Assess for pain at contact points.

ANS: C After an electrical burn, the patient is at risk for fatal dysrhythmias and should be placed on a cardiac monitor. Assessing the oral temperature is not as important as assessing for cardiac dysrhythmias. Checking the potassium level is important. However, it will take time before the laboratory results are back. The first intervention is to place the patient on a cardiac monitor and assess for dysrhythmias, so that they can be treated if occurring. A decreased or increased potassium level will alert the nurse to the possibility of dysrhythmias. The cardiac monitor will alert the nurse immediately of any dysrhythmias. Assessing for pain is important, but the patient can endure pain until the cardiac monitor is attached. Cardiac dysrhythmias can be lethal.

A patient has just arrived in the emergency department after an electrical burn from exposure to a high-voltage current. What is the priority nursing assessment? a. Oral temperature b. Peripheral pulses c. Extremity movement d. Pupil reaction to light

ANS: C All patients with electrical burns should be considered at risk for cervical spine injury, and assessments of extremity movement will provide baseline data. The other assessment data are also necessary but not as essential as determining the cervical spine status

A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first? a. Assess the level of consciousness and pupillary reactions. b. Ascertain the time food or liquid was last consumed. c. Auscultate breath sounds over the trachea and bronchi. d. Measure abdominal girth and auscultate bowel sounds.

ANS: C Inhalation injuries are present in 7% of clients admitted to burn centers. Drooling and difficulty swallowing can mean that the client is about to lose his or her airway because of this injury. Absence of breath sounds over the trachea and bronchi indicates impending airway obstruction and demands immediate intubation. Knowing the level of consciousness is important in assessing oxygenation to the brain. Ascertaining the time of last food intake is important in case intubation is necessary (the nurse will be more alert for signs of aspiration). However, assessing for air exchange is the most important intervention at this time. Measuring abdominal girth is not relevant in this situation.

A nurse teaches a client being treated for a full-thickness burn. Which statement should the nurse include in this client's discharge teaching? a. "You should change the batteries in your smoke detector once a year." b. "Join a program that assists burn clients to reintegration into the community." c. "I will demonstrate how to change your wound dressing for you and your family." d. "Let me tell you about the many options available to you for reconstructive surgery."

ANS: C Teaching clients and family members to perform care tasks such as dressing changes is critical for the progressive goal toward independence for the client. All of the other options are important in the rehabilitation stage. However, dressing changes have priority.

On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse anticipate taking now? a. Monitor urine output every 4 hours. b. Continue to monitor the laboratory results. c. Increase the rate of the ordered IV solution. d. Type and crossmatch for a blood transfusion.

ANS: C The patient's laboratory data show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Because the hematocrit and hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase once the patient's fluid balance has been restored. On admission to a burn unit, the urine output would be monitored more often than every 4 hours; likely every1 hour.

A nurse reviews the laboratory results for a client who was burned 24 hours ago. Which laboratory result should the nurse report to the health care provider immediately? a. Arterial pH: 7.32 b. Hematocrit: 52% c. Serum potassium: 6.5 mEq/L d. Serum sodium: 131 mEq/L

ANS: C The serum potassium level is changed to the degree that serious life-threatening responses could result. With such a rapid rise in potassium level, the client is at high risk for experiencing severe cardiac dysrhythmias and death. All the other findings are abnormal but do not show the same degree of severity; they would be expected in the emergent phase after a burn injury.

A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital. Which action should the nurse take first? a. Stay at the bedside and reassure the patient. b. Administer the ordered morphine sulfate IV. c. Assess orientation and level of consciousness. d. Use pulse oximetry to check the oxygen saturation.

ANS: D Agitation in a patient who may have suffered inhalation injury might indicate hypoxia, and this should be assessed by the nurse first. Administration of morphine may be indicated if the nurse determines that the agitation is caused by pain. Assessing level of consciousness and orientation is also appropriate but not as essential as determining whether the patient is hypoxemic. Reassurance is not helpful to reduce agitation in a hypoxemic patient

Which action will the nurse include in the plan of care for a patient in the rehabilitation phase after a burn injury to the right arm and chest? a. Keep the right arm in a position of comfort. b. Avoid the use of sustained-release narcotics. c. Teach about the purpose of tetanus immunization. d. Apply water-based cream to burned areas frequently.

ANS: D Application of water-based emollients will moisturize new skin and decrease flakiness and itching. To avoid contractures, the joints of the right arm should be positioned in an extended position, which is not the position of comfort. Patients may need to continue the use of opioids during rehabilitation. Tetanus immunization would have been given during the emergent phase of the burn injury

A nurse assesses bilateral wheezes in a client with burn injuries inside the mouth. Four hours later the wheezing is no longer heard. Which action should the nurse take? a. Document the findings and reassess in 1 hour. b. Loosen any constrictive dressings on the chest. c. Raise the head of the bed to a semi-Fowler's position. d. Gather appropriate equipment and prepare for an emergency airway.

ANS: D Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose effective movement of air. When this occurs, wheezing is no longer heard, and neither are breath sounds. These clients can lose their airways very quickly, so prompt action is needed. The client requires establishment of an emergency airway. Swelling usually precludes intubation. The other options do not address this emergency situation.

A nurse cares for a client who has burn injuries. The client's wife asks, "When will his high risk for infection decrease?" How should the nurse respond? a. "When the antibiotic therapy is complete." b. "As soon as his albumin levels return to normal." c. "Once we complete the fluid resuscitation process." d. "When all of his burn wounds have closed."

ANS: D Intact skin is a major barrier to infection and other disruptions in homeostasis. No matter how much time has passed since the burn injury, the client remains at high risk for infection as long as any area of skin is open. Although the other options are important goals in the client's recovery process, they are not as important as skin closure to decrease the client's risk for infection.

A patient who was found unconscious in a burning house is brought to the emergency department by ambulance. The nurse notes that the patient's skin color is bright red. Which action should the nurse take first? a. Insert two large-bore IV lines. b. Check the patient's orientation. c. Assess for singed nasal hair and dark oral mucous membranes. d. Place the patient on 100% oxygen using a non-rebreather mask.

ANS: D The patient's history and skin color suggest carbon monoxide poisoning, which should be treated by rapidly starting oxygen at 100%. The other actions can be taken after the action to correct gas exchange.

Eight hours after a thermal burn covering 50% of a patient's total body surface area (TBSA) the nurse assesses the patient. Which information would be a priority to communicate to the health care provider? a. Blood pressure is 95/48 per arterial line. b. Serous exudate is leaking from the burns. c. Cardiac monitor shows a pulse rate of 108. d. Urine output is 20 mL per hour for the past 2 hours.

ANS: D The urine output should be at least 0.5 to 1.0 mL/kg/hr during the emergent phase, when the patient is at great risk for hypovolemic shock. The nurse should notify the health care provider because a higher IV fluid rate is needed. BP during the emergent phase should be greater than 90 systolic, and the pulse rate should be less than 120. Serous exudate from the burns is expected during the emergent phase

A client has just arrived to the Emergency Department and has sustained burns on the front and back of the right arm and leg. Using the rule of 9s, what is the body surface area percentage? A) 27% B) 18% C) 36% D) 9%

Answer: A Rationale: A nurse can estimate the % of the body area burned using the rule of 9's. Each arm (front and back) is 9% each leg is 9% front and 9% back.

A patient in the emergent/resuscitative phase of a burn injury has had her lab work drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what? A) Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis B) Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis C) Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis D) Hypokalemia, hyponatremia, elevated hematrocrit, and metabolic alkalosis

Answer: A Rationale: Fluid and electrolyte changes in the emergent/resuscitative phase of a burn injury include hyperkalemia related to the release of potassium into the extracellular fluid, hyponatremia from large amount of sodium lost in trapped edema fluid, hemoconcentration that leads to an increased hematocrit, and loss of bicarbonate ions that results in metabolic acidosis.

A 45-year-old man is brought in by Life-Flight after a motor vehicle accident is which he was trapped in a burning vehicle. The burn team is estimating the patient's likelihood of survival based on the severity of the burn injury. The emergency department nurse knows that the severity of the injury is based on what factors? (Select all that apply.) A) Age B) Depth of the burn C) Presence of inhalation injury D) Family support E) Psychological state of the patient

Answer: A, B, C Rationale: The severity of each burn injury is determined by multiple factors that when assessed help the burn team estimate the likelihood that a patient will survive and plan the care for each patient. These factors include age of the patient; depth of the burn; amount of surface area of the body that is burned; presence of inhalation injury; presence of other injuries; location of the injury in special care areas such as the face, perineum, hands, and feet; and presence of a past medical history. Options D and E are not factors that bear on the severity of the injury.

A nurse is caring for a patient with second- and third-degree burns to 50% of the body. The nurse prepares fluid resuscitation based on knowledge of the Parkland (Baxter) formula that includes which recommendation? a. The total 24-hour fluid requirement should be administered in the first 8 hours. b. One half of the total 24-hour fluid requirement should be administered in the first 8 hours. c. One third of the total 24-hour fluid requirement should be administered in the first 4 hours. d. One half of the total 24-hour fluid requirement should be administered in the first 4 hours.

Answer: B Rationale: Fluid resuscitation with the Parkland (Baxter) formula recommends that one half of the total fluid requirement should be administered in the first 8 hours, one quarter of total fluid requirement should be administered in the second 8 hours, and one quarter of total fluid requirement should be administered in the third 8 hours.

The patient in the emergent phase of a burn injury is being treated for pain. What medication should the nurse anticipate using for this patient? a. SQ tetanus toxoid b. IV morphine sulfate c. IM hydromorphone d. PO oxycodone and acetaminophen

Answer: B Rationale: IV medications are used for burn injuries in the emergent phase to rapidly deliver relief and prevent unpredictable absorption as would occur with the IM route. The PO route is not used because GI function is slowed or impaired due to shock or paralytic ileus, although oxycodone and acetaminophen may be used later in the patient's recovery. Tetanus toxoid may be administered but not for pain.

The patient you are caring for has an electrical burn and has developed thick eschar over the burn wound. Which of the following topical antibacterial agents will the nurse expect the physician to order for the wound? A) Silver sulfadiazine 1% (Silvadene) water-soluble cream. B) Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream. C) Silver nitrate 0.5% aqueous solution. D) Acticoat.

Answer: B Rationale: Mafenide acetate 10% hydrophilic-based cream is the agent of choice for electrical burns because of its ability to penetrate thick eschar.

The nurse is preparing the patient for mechanical debridement and informs the patient that this will involve: A) A spontaneous separation of dead tissue from the viable tissue B) Use of surgical scissors, scalpels or forceps to remove the eschar until the point of pain and bleeding occurs C) Shaving of burned skin layers until bleeding, viable tissue is revealed D) Early closure of the wound

Answer: B Rationale: Mechanical debridement can be achieved through the use of surgical scissors, scalpels, or forceps to remove the eschar until the point of pain and bleeding occurs. Mechanical debridement can also be accomplished through the use of topical enzymatic debridement agents. The spontaneous separation of dead tissue from the viable tissue is an example of natural debridement. Early wound closure and shaving the burned skin layers are examples of surgical debridement.

During the care of the patient with a burn in the acute phase, which new interventions should the nurse expect to do after the patient progressed from the emergent phase? a. begin IV fluid replacement b. monitor for signs of complications c. access and manage pain and anxiety d. discuss possible reconstructive surgery

Answer: B Rationale: Monitoring for complications (e.g., wound infection, pneumonia, contractures) is needed in the acute phase. Fluid replacement occurs in the emergent phase. Assessing and managing pain and anxiety occurs in the emergent and the acute phases. Discussing possible reconstructive surgeries is done in the rehabilitation phase.

A nurse taking care of a burn patient is asked why the patient is losing so much weight. What would be the nurse's most appropriate answer? A) "Your body has built up extra fat deposits even though you haven't been eating very much." B) "Your body has used your fat deposits for fuel because you haven't been eating very much." C) Your reserve fat deposits have been catabolized because you have been eating so much." D) You have lost fluids and you haven't eaten very much."

Answer: B Rationale: Patients lose a great deal of weight during recovery from severe burns. Reserve fat deposits are catabolized, fluids are lost, and caloric intake may be limited.

A patient is admitted with second- and third-degree burns covering the face, entire right upper extremity, and the right anterior trunk area. Using the rule of nines, what should the nurse calculate the extent of these burns as being? a. 18% b. 22.5% c. 27% d. 36%

Answer: B Rationale: Using the rule of nines, for these second- and third-degree burns, the face encompasses 4.5% of the body area, the entire right arm encompasses 9% of the body area, and the entire anterior trunk encompasses 18% of the body area. Since the patient has burns on only the right side of the anterior trunk, the nurse would assess that burn as encompassing half of the 18%, or 9%. Therefore adding the three areas together (4.5 + 9 + 9), the nurse would correctly calculate the extent of this patient's burns to cover approximately 22.5% of the total body surface area.

The triage nurse in the emergency department (ED) receives a phone call from a frantic father who saw his 4-year-old child tip a pot of boiling water onto her chest. The father has called an ambulance. What would the nurse in the ED receiving the call instruct the father to do? A) Cover the burn with ice and secure with a towel. B) Apply butter to the area that is burned. C) Immerse the child in a cool bath. D) Avoid touching the burned area and seek medical attention.

Answer: C Rationale: After the flames or heat source have been removed or extinguished, the burned area and adherent clothing are soaked with cool water briefly to cool the wound and halt the burning process. Cool water is the best first-aid measure. You do not put ice on the burn, nor do you put butter on the burn. You do not need to avoid touching the burn.

When caring for a patient with an electrical burn injury, which order from the health care provider should the nurse question? a. mannitol 75 gm IV b. urine for myoglobulin c. LR at 25 mL/h d. sodium bicarbonate 24 mEq q.4h

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

The nursing instructor is going over burn injuries. The instructor tells the students that the nursing care priorities for a patient with a burn injury include wound care, nutritional support, and prevention of complications such as infection. Based upon these care priorities, the instructor is most likely discussing a patient in what phase of burn care? A) Emergent B) Immediate Resuscitative C) Acute D) Rehabilitation

Answer: C Rationale: The acute or intermediate phase of burn care follows the emergent/resuscitative phase and begins 48 to 72 hours after the burn injury. During this phase, attention is directed toward continued assessment and maintenance of respiratory and circulatory status, fluid and electrolyte balance, and gastrointestinal function. Infection prevention, burn wound care (ie, wound cleaning, topical antibacterial therapy, wound dressing, dressing changes, wound debridement, and wound grafting), pain management, and nutritional support are priorities at this stage and are discussed in detail in the following sections. Priorities during the emergent or immediate resuscitative phase include first aid, prevention of shock and respiratory distress, detection and treatment of concomitant injuries, and initial wound assessment and care. The priorities during the rehabilitation phase include prevention of scars and contractures, rehabilitation, functional and cosmetic reconstruction, and psychosocial counseling.

A patient is brought to the Emergency Department from the site of a chemical fire. The paramedics report that the patient has a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. When you assess the patient he verbalizes no pain in the right arm and the skin appears charred. Based upon these assessment findings, what is the depth of the burn on the patient's right arm? A) Superficial partial-thickness B) Deep partial-thickness C) Full partial-thickness D) Full-thickness

Answer: D Rationale: A full-thickness burn involves total destruction of the epidermis and dermis and, in some cases, underlying tissue as well. Wound color ranges widely from white to red, brown, or black. The burned area is painless because the nerve fibers are destroyed. The wound can appear leathery; hair follicles and sweat glands are destroyed. Edema may also be present. Full partial thickness is not a depth of burn. Superficial partial-thickness burns involve the epidermis and possibly a portion of the dermis and the patient will experience pain that is soothed by cooling. Deep partial-thickness burns involve the epidermis, upper dermis, and portion of the deeper dermis and the patient will complain of pain and sensitivity to cold air.

In caring for a patient with burns to the back, the nurse knows that the patient is moving out of the emergent phase of burn injury when what happens? a. Serum sodium and potassium increase b. Serum sodium and potassium decrease. c. Edema and arterial blood gases improve. d. Diuresis occurs and hematocrit decreases.

Answer: D Rationale: 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 RBCs and thrombosis of burned capillaries also decreases circulating RBCs. When the fluid balance has been restored, dilution causes the hematocrit levels to drop. Initially sodium moves to the interstitial spaces and remains there until edema formation ceases, so sodium levels increase at the end of the emergent phase as the sodium moves back to the vasculature. Initially potassium level increases as it is released from injured cells and hemolyzed RBCs, so potassium levels decrease at the end of the emergent phase when fluid levels normalize.

A patient is admitted to the burn center with burns of his head and neck, chest, and back after an explosion in his garage. On assessment, the nurse auscultates wheezes throughout the lung fields. On reassessment, the wheezes are gone and the breath sounds are greatly diminished. Which action is the most appropriate for the nurse to take next? A) obtain vital signs and a STAT ABG B) encourage the patient to cough and auscultate the lungs again C) document the findings and continue to monitor the patient's breathing D) anticipate the need for endotracheal intubation and notify the physician

Answer: D Rationale: Inhalation injury results in exposure of the respiratory tract to intense heat or flames with inhalation of noxious chemicals, smoke, or carbon monoxide. The nurse should anticipate the need for intubation and mechanical ventilation because this patient is demonstrating signs of severe respiratory distress.

The nurse is caring for a patient who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis? A) Activity intolerance B) Anxiety C) Impaired nutrition: less than body requirements D) Acute pain

Answer: D Rationale: Pain is inevitable during recovery from any burn injury. Pain in the burn patient has been described as one of the most severe causes of acute pain. Management of the often-severe pain is one of the most difficult challenges facing the burn team. While the other nursing diagnoses listed are valid diagnoses, the presence of pain may contribute to these diagnoses and management of the patient's pain is priority as it may have a direct correlation to these nursing diagnoses.

A patient is brought to the ED by paramedics who report the patient has partial-thickness burns on the chest and legs. The patient has also suffered smoke inhalation. What is a priority in the care of a patient who has been burned and suffered smoke inhalation? A) Pain B) Fluid balance C) Anxiety and fear D) Airway management

Answer: D Rationale: Systemic threats from a burn are the greatest threat to life. The ABCs of all trauma care apply during the early postburn period. While all options should be addressed, pain, fluid balance, and anxiety and fear do not take precedence over airway management.

A patient with a burn inhalation injury is receiving albuterol (Ventolin) for bronchospasm. What is the most important adverse effect of this medication for the nurse to manage? A. GI distress B. Tachycardia C. Restlessness D. Hypokalemia

B. Tachycardia Albuterol (Ventolin) stimulates β-adrenergic receptors in the lungs to cause bronchodilation. However, it is a non-cardioselective agent so it also stimulates the β-receptors in the heart to increase the heart rate. Restlessness and GI upset may occur but will decrease with use. Hypokalemia does not occur with albuterol.

An 82-year-old patient is moving into an independent living facility. What is the best advice the nurse can give to the family to help prevent this patient from being accidently burned in her new home? A. Cook for her. B. Stop her from smoking. C. Install tap water anti-scald devices. D. Be sure she uses an open space heater.

C. Install tap water anti-scald devices. Installing tap water anti-scald devices will help prevent accidental scald burns that more easily occur in older people as their skin becomes drier and the dermis thinner. Cooking for her may be needed at times of illness or in the future, but she is moving to an independent living facility, so at this time she should not need this assistance. Stopping her from smoking may be helpful to prevent burns but may not be possible without the requirement by the facility. Using an open space heater would increase her risk of being burned and would not be encouraged.

When caring for a patient with an electrical burn injury, which order from the health care provider should the nurse question? A. Mannitol 75 gm IV B. Urine for myoglobulin C. Lactated Ringer's at 25 mL/hr D. Sodium bicarbonate 24 mEq every 4 hours

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

A 25-year-old patient is admitted with partial-thickness injuries over 20% of the total body surface area involving both lower legs. The nurse would classify this injury as being which of the following? 1. a moderate burn 2. a minor burn 3. a major burn 4. a severe burn 5. an intermediate burn

Correct Answer: 1 Rationale 1: A moderate burn is a partial-thickness injury that is between 15%-25% of total body surface area in adults.

A patient who is being treated with topical mafenide acetate for third-degree burns is demonstrating facial and neck edema. The nurse realizes that this patient most likely 1. is developing a hypersensitivity to the medication. 2. is reacting positively to the medication. 3. needs an increase in dosage of the medication. 4. is not responding to the medication.

Correct Answer: 1 Rationale: Approximately 3%-5% of patients develop a hypersensitivity to mafenide, which can manifest as facial edema. The manifestation of facial and neck edema is considered an adverse reaction. There is inadequate information presented to assess response to the medication.

A patient is being evaluated after experiencing severe burns to his torso and upper extremities. The nurse notes edema at the burned areas. Which of the following best describes the underlying cause for this assessment finding? 1. inability of the damaged capillaries to maintain fluids in the cell walls 2. reduced vascular permeability at the site of the burned area 3. decreased osmotic pressure in the burned tissue 4. increased fluids in the extracellular compartment 5. the IV fluid being administered too quickly

Correct Answer: 1 Rationale: Burn shock occurs during the first 24-36 hours after the injury. During this period, there is an increase in microvascular permeability at the burn site. The osmotic pressure is increased, causing fluid accumulation. There is a reduction of fluids in the extracellular body compartments. Manifestations of fluid volume overload would be systemic, not localized to the burn areas.

A patient has experienced a burn injury. Which of the following interventions by the nurse is of the highest priority at this time? 1. determination of the type of burn injury 2. determination of the types of home remedies attempted prior to the patient's coming to the hospital 3. assessment of past medical history 4. determination of body weight 5. determination of nutritional status

Correct Answer: 1 Rationale: Determination of the type of burn is the first step. The type of injury will dictate the interventions performed. Determining the use of home remedies, past medical history, body weight, and nutritional status must be completed, but are not of the highest priority.

A patient with third-degree burns is prescribed gastrointestinal medication. The primary action of this drug is which of the following? 1. to prevent the onset of a Curling's ulcer 2. to treat a preexisting duodenal ulcer 3. to ensure adequate peristalsis 4. for the antiemetic properties

Correct Answer: 1 Rationale: Dysfunction of the gastrointestinal system is directly related to the size of the burn wound. This can lead to a cessation of intestinal motility, which causes gastric distention, nausea, vomiting, and hematemesis. Stress ulcers or Curling's ulcers are acute ulcerations of the stomach or duodenum that form following the burn injury. There is no evidence to support the presence of a preexisting duodenal ulcer. Although peristalsis is desired, it is not the primary area of gastrointestinal concern. There is no data presented to indicate the presence of nausea or vomiting.

The nurse is providing care to a patient with a third-degree burn on his left thigh and left forearm. During wound care, the nurse applies Elase to the burned areas. Which of the following types ofwound debridement is this nurse using? 1. enzymatic 2. mechanical 3. surgical 4. topical

Correct Answer: 1 Rationale: Enzymatic debridement involves the use of a topical agent to dissolve and remove necrotic tissue. An enzyme such as Elase is applied in a thin layer directly to the wound and covered with one layer of fine mesh gauze. A topical antimicrobial agent is then applied and covered with a bulky wet dressing. Mechanical debridement may be performed by applying and removing gauze dressings, hydrotherapy, irrigation, or using scissors and tweezers. Surgical debridement is the process of excising the wound to the fascia or removing thin slices of the burn to the level of viable tissue. Topical treatments are key in the care of a burn but do not involve debridement.

The nurse is evaluating the adequacy of a burn-injured patient's nutritional intake. Which of the following laboratory values is the best indicator of a need to adjust the nutritional program? 1. glycosuria 2. creatine phosphokinase (CPK) 3. BUN levels 4. hemoglobin 5. serum sodium levels

Correct Answer: 1 Rationale: Glucose in the urine is seen after a major burn injury. It signals the need to reevaluate the patient's nutritional plan. Creatine phosphokinase is used to identify the presence of muscle injuries. BUN levels are used to evaluate kidney function. Hemoglobin levels will fluctuate with the stages of the burn injury dependent upon the fluid status. Serum sodium levels are not indicative of nutritional status.

When evaluating the laboratory values of the burn-injured patient, which of the following can be anticipated? 1. decreased hemoglobin and elevated hematocrit levels 2. elevated hemoglobin and elevated hematocrit levels 3. elevated hemoglobin and decreased hematocrit levels 4. decreased hemoglobin and decreased hematocrit levels 5. hemoglobin and hematocrit levels within normal ranges

Correct Answer: 1 Rationale: Hemoglobin levels are reduced in response to the hemolysis of red blood cells. Hematocrit levels are elevated secondary to hemoconcentration, and fluid shifts from the intravascular compartment.

A patient with third-degree burns is being treated with high-volume intravenous fluids and has a urine output of 40 cc per hour. The nurse realizes that this urine output 1. is normal for this patient. 2. provides evidence that the patient is dehydrated. 3. provides evidence that the patient is over-hydrated. 4. is indicative of pending renal failure.

Correct Answer: 1 Rationale: Intake and output measurements indicate the adequacy of fluid resuscitation, and should range from 30 to 50 mL per hour in an adult.

A patient recovering from a major burn injury is complaining of pain. Which of the following medications will be most therapeutic to the patient? 1. morphine 4 mg IV every 5 minutes 2. morphine 10 mg IM ever 3-4 hours 3. meperidine 75 mg IM every 3-4 hours 4. meperidine 50 mg PO every 3-4 hours 5. fentanyl citrate (Duragesic) 75 mcg patch every 3 days

Correct Answer: 1 Rationale: Morphine is preferred over meperidine for the burn-injured patient. Typical dose of morphine is 3-5 mg every 5-10 minutes for an adult. The intravenous route is preferred over oral and intramuscular routes. A transdermal patch would not be used because of decreased absorption of the medication through the skin of the burn-injured patient.

A 70-year-old patient has experienced a sunburn over much of the body. What self-care technique is MOST important to emphasize to an older adult in dealing with the effects of the sunburn? 1. increasing fluid intake 2. applying mild lotions 3. taking mild analgesics 4. maintaining warmth 5. using sunscreen

Correct Answer: 1 Rationale: Older adults are especially prone to dehydration; therefore, increasing fluid intake is especially important. Other manifestations could include nausea and vomiting. All the measures help alleviate the manifestations of this minor burn which include pain, skin redness, chills, and headache. Use of sunscreen is a preventative, not a treatment measure.

The nurse notes that a patient with third-degree burns is demonstrating a reduction in his serum potassium level. The nurse realizes that this finding is consistent with which of the following? 1. the resolution of burn shock 2. the onset of burn shock 3. the onset of renal failure 4. the onset of liver failure

Correct Answer: 1 Rationale: Potassium levels are initially elevated during burn shock but will decrease after burn shock resolves as fluid shifts back to intracellular and intravascular compartments. Reduced potassium levels are not indicators of the onset of renal or liver failure.

Following surgical debridement, a patient with third-degree burns does not bleed. The nurse realizes that this patient 1. will need to have the procedure repeated. 2. will no longer need this procedure. 3. will need to be premedicated prior to the next procedure. 4. should have an escharotomy instead.

Correct Answer: 1 Rationale: Surgical debridement is the process of excising the burn wound by removing thin slices of the wound to the level of viable tissue. If bleeding does not occur after the procedure, it will be repeated. It is an assumption that patients having debridement will all require premedication. An escharotomy involves removal of the hardened crust covering the burned area.

When monitoring the vital signs of the patient who has experienced a major burn injury, the nurse assesses a heart rate of 112 and a temperature of 99.9° F. Which of the following best describes the findings? 1. These values are normal for the patient's post-burn injury condition. 2. The patient is demonstrating manifestations consistent with the onset of an infection. 3. The patient is demonstrating manifestations consistent with an electrolyte imbalance. 4. The patient is demonstrating manifestations consistent with renal failure. 5. The patient is demonstrating manifestations of fluid volume overload.

Correct Answer: 1 Rationale: The burn-injured patient is not considered tachycardic until the heart rate reaches 120 beats per minute. In the absence of other symptoms, the temperature does not signal the presence of an infection. It could be a response to a hypermetabolic response.

A patient with third-degree burns to his right arm is scheduled for passive range of motion to the extremity every two hours. Which of the following should the nurse do prior to this exercise session? 1. Medicate for pain. 2. Empty the patient's in-dwelling catheter collection bag. 3. Change the patient's bed linens. 4. Change the dressing on the burn.

Correct Answer: 1 Rationale: The nurse should anticipate this patient's needs for analgesia and administer pain medication to promote the patient's comfort during the exercise session. Arm exercise is not related to the amount of urine in the catheter bag. Linen changes do not impact range of motion activities. The burn's dressing is changed according to the physician's orders or as needed.

A patient is scheduled for surgery to graft a burn injury on the arm. Which of the following statements should the nurse include when instructing the patient prior to the procedure? 1. "You will begin to perform exercises to promote flexibility and reduce contractures after five days." 2. "You will need to report any itching, as it might signal infection." 3. "Performing the procedure near the end of the hospitalization will reduce the incidence of infection and improve success of the procedure." 4. "The procedure will be performed in your room." 5. "You will need to be in protective isolation for several weeks after the graft is performed."

Correct Answer: 1 Rationale: The patient will begin to perform range-of-motion exercises after five days. Itching is not a symptom of infection but an anticipated occurrence that signals cellular growth. The ideal time to perform the procedure is early in the treatment of the burn injury. The procedure is performed in a surgical suite. Patients with skin grafts do not require protective isolation.

A patient receiving treatment for severe burns over more than half of his body has an indwelling urinary catheter. When evaluating the patient's intake and output, which of the following should be taken into consideration? 1. The amount of urine will be reduced in the first 24-48 hours, and will then increase. 2. The amount of urine output will be greatest in the first 24 hours after the burn injury. 3. The amount of urine will be reduced during the first eight hours of the burn injury and will then increase as the diuresis begins. 4. The amount of urine will be elevated due to the amount of intravenous fluids administered during the initial phases of treatment. 5. The amount of urine is expected to be decreased for three to five days.

Correct Answer: 1 Rationale: The patient will have an initial reduction in urinary output. Fluid is reduced in the initial phases as the body manages the insult caused by the injury and fluids are drawn into the interstitial spaces. After the shock period passes, the patient will enter a period of diuresis. The diuresis begins between 24 and 36 hours after the burn injury.

The family of a patient with third-degree burns wants to know why the "scabs are being cut off" of the patient's leg. What is the most appropriate response by the nurse to this family? 1. "The scabs are really old burned tissue and need to be removed to promote healing." 2. "I'll ask the doctor to come and talk with you about the treatment plan." 3. "The patient asked for the scabs to be removed." 4. "The scabs are removed to check for blood flow to the burned area."

Correct Answer: 1 Rationale: The patient's family is describing eschar, which is the hard crust of burned necrotic tissue. Eschar needs to be removed to promote wound healing. Option 2 does not answer the family's question. Option 3 incorrectly restates the family's concern. Scabs are not removed to check for blood flow.

A patient, experiencing a burn that is pale and waxy with large flat blisters, asks the nurse about the severity of the burn and how long it will take to heal. With which of the following should the nurse respond to this patient? 1. The wound is a deep partial-thickness burn, and will take more than three weeks to heal. 2. The wound is a partial-thickness burn, and could take up to two weeks to heal. 3. The wound is a superficial burn, and will take up to three weeks to heal. 4. The wound is a full-thickness burn and will take one to two weeks to heal. 5. Wound healing is individualized.

Correct Answer: 1 Rationale: The wound described is a deep partial-thickness burn. Deep partial-thickness wounds will take more than three weeks to heal. A superficial burn is bright red and moist, and might appear glistening with blister formation. The healing time for this type of wound is within 21 days. A full thickness burn involves all layers of the skin and may extend into the underlying tissue. These burns take many weeks to heal. Stating that wound healing is individualized does not answer the patient's question about the severity of the burn.

A patient with third-degree burns to her face just learned that she will have extensive scarring once the burn heals. Which of the following nursing diagnoses would be applicable to this patient at this time? 1. Powerlessness 2. Potential for Infection 3. Fluid Volume Deficit 4. Risk for Ineffective Airway Clearance

Correct Answer: 1 Rationale: This patient can begin to experience powerlessness in that she has no control over the outcome of healing on scar formation to her face. The nurse should allow the patient to express feelings in efforts to help the patient cope with the news of potential scarring. The patient with a third-degree burn is at risk for infection, however, this question is focused on the impact of her facial scarring. There is inadequate information to determine the patient's risk for fluid volume deficit or ineffective airway clearance. Further, this is not the focus of the question.

A patient is coming into the emergency department with third-degree burns over 25% of his body. The nurse should prepare which of the following solutions for intravenous infusion for this patient? 1. warmed lactated Ringer's 2. 5% dextrose in water 3. 5% dextrose in 0.45 normal saline 4. 5% dextrose in normal saline

Correct Answer: 1 Rationale: Warmed Ringer's lactate solution is the intravenous fluid most widely used during the first 24 hours after a burn injury because it most closely approximates the body's extracellular fluid composition.

A patient is admitted to the emergency department with deep partial-thickness burns over 35 % of the body. What IV solution will be started initially? 1. warmed lactated Ringer's solution 2. dextrose 5% with saline solution 3. dextrose 5% with water 4. normal saline solution 5. 0.45% saline solution

Correct Answer: 1 Rationale: Warmed lactated Ringer's solution is the IV solution of choice because it most closely approximates the body's extracellular fluid composition. It is warmed to prevent hypothermia.

A patient has a scald burn on the arm that is bright red, moist, and has several blisters. The nurse would classify this burn as which of the following? Select all that apply. 1. a superficial partial-thickness burn 2. a thermal burn 3. a superficial burn 4. a deep partial-thickness burn 5. a full-thickness burn

Correct Answer: 1,2 Rationale: Superficial partial-thickness burn if often bright red, has a moist, glistening appearance and blister formation. Thermal burns result from exposure to dry or moist heat. A superficial burn is reddened with possible slight edema over the area. A deep partial-thickness burn often appears waxy and pale and may be moist or dry. A full-thickness burn may appear pale, waxy, yellow, brown, mottled, charred, or non-blanching red with a dry, leathery, firm wound surface.

The nurse is reviewing the results of laboratory tests to assess the renal status of a patient who experienced a major burn event on 45% of the body 24 hours ago. Which of the following results would the nurse expect to see? (Select all that apply) 1. glomerular filtration rate (GFR) reduced 2. specific gravity elevated 3. creatinine clearance reduced 4. BUN reduced 5. uric acid decreased

Correct Answer: 1,2 Rationale: During the initial phases of a burn injury, blood flow to the renal system is reduced, resulting in reduction in GFR and an increase in specific gravity. During this period, BUN levels, creatinine, and uric acid are increased

A patient with a burn injury is prescribed silver nitrate. Which of the following nursing interventions should be included for the patient? Standard Text: Select all that apply. 1. Monitor daily weight. 2. Monitor the serum sodium levels. 3. Prepare to change the dressings every two hours. 4. Report black skin discolorations. 5. Push fluid intake.

Correct Answer: 1,2 Rationale: Silver nitrate can cause hypotonicity. Manifestations of hypotonicity include weight gain and edema, which can be monitored by the determination of daily weights. Hyponatremia and hypochloremic alkalosis are common findings in patients treated with silver nitrate so serum sodium and chloride should be monitored. Changing the dressing every two hours is too frequent for the patient. Black discolorations of the skin are anticipated for patients using silver nitrate, and do not highlight a complication of therapy. Silver sulfadiazine, not silver nitrate, administration can result in the development of sulfa crystals in the urine so pushing fluid intake is not an appropriate action for this patient.

A patient is being discharged after treatment for a scald burn that caused a superficial burn over one hand and a superficial partial-thickness burn on several fingers. What should be included in this patient's discharge instructions? (Select all that apply) 1. Report any fever to your healthcare provider. 2. Report development of purulent drainage to your healthcare provider. 3. Use only sterile dressings on the fingers. 4. Cleanse the areas every hour with alcohol to prevent infection. 5. Apply the topical antimicrobial agent as instructed.

Correct Answer: 1,2,3 Rationale: Fever or purulent drainage are indicative of development of infection and should be reported to the healthcare provider. Sterile dressings only should be used on the areas of the superficial partial-thickness burns where the skin is not intact. Cleansing is necessary no more often than daily to the intact skin areas and only soap and water should be used, not alcohol. Topical agents may be ordered by the health care provider and the patient should follow directions for applying to help prevent infection of the areas.

A patient arrives at the emergency department with an electrical burn. What assessment questions should the nurse ask in determining the possible severity of the burn injury? Select all that apply. 1. What type of current was involved? 2. How long was the patient in contact with the current? 3. How much voltage was involved? 4. Where was the patient when the burn occurred? 5. What was the point of contact with the current?

Correct Answer: 1,2,3 Rationale: The severity of electrical burns depends on the type and duration of the current and amount of voltage. Location is not important in determining possible severity. Location is not important in determining possible severity.

A nurse is teaching a class of older adults at a senior center about household cleaning agents that may cause burns. Which agents should be included in these instructions? (Select all that apply) 1. drain cleaners 2. household ammonia 3. oven cleaner 4. toiler bowl cleaner 5. lemon oil furniture polish

Correct Answer: 1,2,3,4 Rationale: All of the products except for the furniture polish can cause burns since they are either alkalis or acids.

In order for the nurse to correctly classify a burn injury, which of the following does the nurse need to assess? Select all that apply. 1. the depth of the burn 2. extent of burns on the body 3. the causative agent and the duration of exposure. 4. location of burns on the body 5. the time that the burn occurred

Correct Answer: 1,2,3,4 Rationale: Depth of the burn (the layers of underlying tissue affected) and extent of the burn (the percentage of body surface area involved) are used in determining the amount of tissue damage and classification of the burn.The causative agent is especially important with chemical burns such as from strong acids or alkaline agents. The location of the burns on the body is one of the important determinates of classification. For example, burns of the face and hands are always considered major burns. Time of occurrence of the burn is not necessary for classification.

During the acute phase of burn treatment, important goals of patient care include which of the following? Select all that apply. 1. providing for patient comfort 2. preventing infection 3. providing adequate nutrition for healing to occur 4. splinting, positioning, and exercising affected joints 5. assessing home maintenance management

Correct Answer: 1,2,3,4 Rationale: The goals of treatment for the acute period include wound cleansing and healing; pain relief; preventing infection; promoting nutrition; and splinting, positioning, and exercising affected joints. Assessment of home maintenance management is an important goal in the rehabilitative stage, not the acute stage.

A patient comes into the clinic to be seen for a burn that appears moist with blisters. The nurse realizes that this patient most likely has experienced which of the following? 1. first-degree burn 2. superficial second-degree burn 3. deep second-degree burn 4. third-degree burn

Correct Answer: 2 Rationale: Partial-thickness, or second-degree, burns can either be superficial or deep. This patient's burn, which appears moist with blisters, is consistent with a superficial second-degree burn. A first-degree burn would involve only the surface layer of skin. Redness would be expected. Deep second-degree and third-degree burns would be deeper and involve more damage to the dermis, epidermis, and underlying tissue.

Using the modified Brooke formula, calculate the amount of intravenous solution that will be administered in the first 8 hours for a patient with 40% TBSA and weighs 52 kg.

Correct Answer: 2080 mL Rationale : The modified Brooke formula is 2 mL × total kg of body weight × % TBSA. In this situation, 2 mL × 52 kg × 40 = 4160 mL. One-half is given over the first eight hours, or 2080 mL.

A patient is brought to the emergency department with the following burn injuries: a blistered and reddened anterior trunk, reddened lower back, and pale, waxy anterior right arm. Calculate the extent of the burn injury (TBSA) using the rule of nines.

Correct Answer: 22.5 Rationale : The anterior trunk has superficial partial-thickness burns and is calculated in TBSA as 18%. The arm has a deep partial-thickness burn and is calculated as 4.5%. The burn on the lower back is superficial and is not calculated in TBSA.

A patient comes into the physician's office after sustaining chemical burns to the left side of his face and right wrist. The nurse realizes that this patient needs to be treated 1. in the outpatient ambulatory clinic. 2. in the emergency department. 3. in a burn center. 4. in the doctor's office and then at home.

Correct Answer: 3 Rationale: Adult patients who should be treated at burn centers include those with burns that involve the hands, feet, face, eyes, ears, or perineum. Patients having small or noninvasive burns may be managed at an outpatient clinic are mild in nature. The emergency department is a location for evaluation of a burn. The physician's office like the ambulatory clinic can manage mild burns.

A female patient comes into the clinic complaining of nausea and vomiting after spending the weekend at a seaside resort. Which of the following should be the most important assessment for the nurse? 1. normal rest and sleep pattern 2. typical meal pattern 3. if the patient had to change time zones when traveling to the resort 4. if the patient has been sunburned

Correct Answer: 4 Rationale: Sunburns result from exposure to ultraviolet light. Because the skin remains intact, the manifestations in most cases are mild and are limited to pain, nausea, vomiting, skin redness, chills, and headache. The patient has not reported concerns which will support issues with sleep pattern, diet, and travel.

To maintain a positive nitrogen balance in a major burn, the patient must: a. eat a high-protein, low-fat, high-carbohydrate diet b. increase normal caloric intake by about three times c. eat at least 1500 calories/day in small, frequent meals d. eat rice and whole wheat for the chemical effect on nitrogen balance.

Correct answer: a Rationale: The patient should be encouraged to eat high-protein, high-carbohydrate foods to meet increased caloric needs. Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. Failure to supply adequate calories and protein leads to malnutrition and delays in healing.

A therapeutic measure used to prevent hypertrophic scarring during rehabilitation phase of burn recover is: a. applying pressure garments b. repositioning the patient every 2 hours c. performing active ROM at least every 4 hours d. massaging the new tissue with water-based moisturizers

Correct answer: a Rationale: Pressure can help keep a scar flat and reduce hypertrophic scarring. Gentle pressure can be maintained on the healed burn with custom-fitted pressure garments.

A patient has 25% TBSA burned from a car fire. His wounds have been debrided and covered with a silver-impregnated dressing. The nurse's priority intervention for wound care would be to: a. reapply a new dressing without disturbing the wound bed b. observe the wound for signs of infection during dressing changes c. apply cool compresses for pain relief in between dressing changes d. wash the wound aggressively with soap and water three times a day.

Correct answer: b Rationale: Infection is the most serious threat with regard to further tissue injury and possible sepsis.

Fluid and electrolyte shifts that occur during the early emergent phase of a burn injury include: a. adherence of albumin to vascular walls b. movement of potassium into vascular space c. sequestering of sodium and water in interstitial fluid d. hemolysis of red blood cells from large volumes of rapidly administered fluid

Correct answer: c Rationale: During the emergency phase, sodium rapidly shifts to the interstitial spaces and remains there until edema formation ceases.

A patient is recovering from second- and third-degree burns over 30% of his body and is now ready for discharge. The first action the nurse should take when meeting with the patient would be to: a. arrange a return-to-clinic appointment and prescription for pain medications b. teach the patient and caregiver proper wound care to be performed at home c. review the patient's current health care status and readiness for discharge to home d. give the patient written discharge information and websites for additional information for burn survivors.

Correct answer: c Rationale: Recovery from a burn injury to 30% of total body surface area (TBSA) takes time and is exhausting, both physically and emotionally, for the patient. The health care team may think that a patient is ready for discharge, but the patient may not have any idea that discharge is being contemplated in the near future. Patients are often very fearful about how they will manage at home. The patient would benefit from the nurse's careful review of his or her progress and readiness for discharge; then the nurse should outline the plans for support and follow-up after discharge.

A patient is admitted to the burn center with burns of his head and neck, chest, and back after an explosion in his garage. On assessment, the nurse auscultates wheezes throughout the lung fields. On reassessment, the wheezes are gone and the breath sounds are greatly diminished. Which action is the most appropriate for the nurse to take next? a. obtain vital signs and a STAT ABG b. encourage the patient to cough and auscultate the lungs again c. document the findings and continue to monitor the patient's breathing d. anticipate the need for endotracheal intubation and notify the physician

Correct answer: d Rationale: Inhalation injury results in exposure of the respiratory tract to intense heat or flames with inhalation of noxious chemicals, smoke, or carbon monoxide. The nurse should anticipate the need for intubation and mechanical ventilation because this patient is demonstrating signs of severe respiratory distress.

Pain management for the burn patient is most effective when (SATA): a. a pain rating tool is used to monitor the patient's level of pain b. painful dressing changes are delayed until the patient's pain is completely relieved c. the patient is informed about and has some control over the management of the pain d. a multi-modal approach is used (e.g., sustained-release and short-acting opioids, NSAIDS, adjuvant analgesics). e. non-pharmacological therapies (e.g., music therapy, distraction) replace opioids in the rehabilitation phase of a burn injury

Correct answers: a, c, d Rationale: The use of a pain rating tool assists the nurse in the assessment, monitoring, and evaluation of the pain management plan. The more control the patient has in managing the pain, the more successful the chosen strategies are. A selected variety of medications offer better pain relief for patients with burns, whose pain can be both continuous and treatment related over varying periods of time. It is not realistic to promise a patient that pain will be completely eliminated. It is not realistic to suggest that pain will be managed (during any phase of burn care) with nonpharmacologic pain management. Such management is meant to be adjuvant and individualized.

Place an "X" over the section of the diagram that represents the depth of a superficial partial-thickness burn. [insert Use figure 16-17 in LeMone 5E. Remove the caption and the labels on the right side (Clark's levels). Retain the left side labels (Skin layers). The Roman numeral labels in the drawing may remain if necessary.]

Rationale : A superficial partial-thickness burn damages the entire epidermis and through the papillary dermis.

A patient is admitted to the emergency department with first- and second-degree burns after being involved in a house fire. Which assessment findings would alert you to the presence of an inhalation injury? (select all that apply)? A. Singed nasal hair B. Generalized pallor C. Painful swallowing D. Burns on the upper extremities E. History of being involved in a large fire

A, B, C, E. Reliable clues to the occurrence of inhalation injury is the presence of facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral and nasal membranes, carbonaceous sputum, history of being burned in an enclosed space, altered mental status, and "cherry red" skin color.

A patient has sustained a partial-thickness injury of 28% of total body surface area (TBSA) and full-thickness injury of 30% or greater of TBSA. How should the nurse classify this burn injury? 1. major 2. moderate 3. minor 4. superficial 5. intermediate

Correct Answer: 1 Rationale 1: Partial-thickness injuries of greater than 25% of total body surface area in adults and full-thickness injuries 10% or greater of TBSA are considered major burns.

A nurse sees a patient get struck by lightning during a thunder storm on a golf course. What should be the FIRST action by the nurse? 1. Check breathing and circulation. 2. Look for entrance and exit wounds. 3. Cover the patient to prevent heat loss. 4. Move the patient indoors to a dry place. 5. Get the patient up off the ground.

Correct Answer: 1 Rationale: Cardiopulmonary arrest is the most common cause of death from lightening. Respiratory and cardiac status should be assessed immediately to determine if CPR is necessary. All other actions are secondary.

The nurse is planning care for a patient with partial- and full-thickness skin destruction related to burn injury of the lower extremities. Which interventions should the nurse expect to include in this patient's care? (Select all that apply.) A. Escharotomy B. Administration of diuretics C. IV and oral pain medications D. Daily cleansing and debridement E. Application of topical antimicrobial agent

A, C, D, E. An escharotomy (a scalpel incision through full-thickness eschar) is frequently required to restore circulation to compromised extremities. Daily cleansing and debridement as well as application of an antimicrobial ointment are expected interventions used to minimize infection and enhance wound healing. Pain control is essential in the care of a patient with a burn injury. With full-thickness burns, myoglobin and hemoglobin released into the bloodstream can occlude renal tubules. Adequate fluid replacement is used to prevent this occlusion.

An emergency room nurse assesses a client who was rescued from a home fire. The client suddenly develops a loud, brassy cough. Which action should the nurse take first? a. Apply oxygen and continuous pulse oximetry. b. Provide small quantities of ice chips and sips of water. c. Request a prescription for an antitussive medication. d. Ask the respiratory therapist to provide humidified air.

ANS: A Brassy cough and wheezing are some of the signs seen with inhalation injury. The first action by the nurse is to give the client oxygen. Clients with possible inhalation injury also need continuous pulse oximetry. Ice chips and humidified room air will not help the problem, and antitussives are not warranted.

A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first? a. Auscultate the patient's lung sounds. b. Determine the extent and depth of the burns. c. Infuse the ordered lactated Ringer's solution. d. Administer the ordered hydromorphone (Dilaudid).

ANS: A A patient with facial and chest burns is at risk for inhalation injury, and assessment of airway and breathing is the priority. The other actions will be completed after airway management is assured.

The occupational health nurse is called to the floor of a factory where a patient has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to "cool the burn." How will the nurse cool the burn? A) Apply ice to the site of the burn for 5 to 10 minutes. B) Wrap the patient's affected extremity in ice until help arrives. C) Apply an oil-based substance or butter to the burned area until help arrives. D) Wrap cool towels around the affected extremity intermittently.

Answer: D Rationale: Once the burn has been sustained, the application of cool water is the best first-aid measure. Soaking the burn area intermittently in cool water or applying cool towels gives immediate and striking relief from pain and limits local tissue edema and damage. However, never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns.

A patient is admitted with second- and third-degree burns covering the face, entire right upper extremity, and the right anterior trunk area. Using the rule of nines, what should the nurse calculate the extent of these burns as being? A. 18% B. 22.5% C. 27% D. 36%

B. 22.5% Using the rule of nines, for these second- and third-degree burns, the face encompasses 4.5% of the body area, the entire right arm encompasses 9% of the body area, and the entire anterior trunk encompasses 18% of the body area. Since the patient has burns on only the right side of the anterior trunk, the nurse would assess that burn as encompassing half of the 18%, or 9%. Therefore adding the three areas together (4.5 + 9 + 9), the nurse would correctly calculate the extent of this patient's burns to cover approximately 22.5% of the total body surface area.

The patient in the emergent phase of a burn injury is being treated for pain. What medication should the nurse anticipate using for this patient? A. SQ tetanus toxoid B. IV morphine sulfate C. IM hydromorphone (Dilaudid) D. PO oxycodone and acetaminophen (Percocet)

B. IV morphine sulfate IV medications are used for burn injuries in the emergent phase to rapidly deliver relief and prevent unpredictable absorption as would occur with the IM route. The PO route is not used because GI function is slowed or impaired due to shock or paralytic ileus, although oxycodone and acetaminophen may be used later in the patient's recovery. Tetanus toxoid may be administered but not for pain.

During the care of the patient with a burn in the acute phase, which new interventions should the nurse expect to do after the patient progressed from the emergent phase? A. Begin IV fluid replacement. B. Monitor for signs of complications. C. Assess and manage pain and anxiety. D. Discuss possible reconstructive surgery.

B. Monitor for signs of complications. Monitoring for complications (e.g., wound infection, pneumonia, contractures) is needed in the acute phase. Fluid replacement occurs in the emergent phase. Assessing and managing pain and anxiety occurs in the emergent and the acute phases. Discussing possible reconstructive surgeries is done in the rehabilitation phase.

When assessing a patient with a partial-thickness burn, the nurse would expect to find (SATA): a. blisters b. exposed fascia c. exposed muscles d. intact nerve endings e. red, shiny, wet appearance

Correct answers: a, d, e Rationale: The appearance of partial-thickness (deep) burns may include fluid-filled vesicles (blisters) that are red, shiny, or wet (if vesicles have ruptured). Patients may have severe pain caused by exposure of nerve endings and may have mild to moderate edema.

In caring for a patient with burns to the back, the nurse knows that the patient is moving out of the emergent phase of burn injury when what happens? A. Serum sodium and potassium increase B. Serum sodium and potassium decrease. C. Edema and arterial blood gases improve. D. Diuresis occurs and hematocrit decreases.

D. Diuresis occurs and hematocrit decreases. 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 RBCs and thrombosis of burned capillaries also decreases circulating RBCs. When the fluid balance has been restored, dilution causes the hematocrit levels to drop. Initially sodium moves to the interstitial spaces and remains there until edema formation ceases, so sodium levels increase at the end of the emergent phase as the sodium moves back to the vasculature. Initially potassium level increases as it is released from injured cells and hemolyzed RBCs, so potassium levels decrease at the end of the emergent phase when fluid levels normalize.

The nurse is caring for a patient with partial- and full-thickness burns to 65% of the body. When planning nutritional interventions for this patient, what dietary choices should the nurse implement? A. Full liquids only B. Whatever the patient requests C. High-protein and low-sodium foods D. High-calorie and high-protein foods

D. High-calorie and high-protein foods A hypermetabolic state occurs proportional to the size of the burn area. Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. Caloric needs are often in the 5000-kcal range. Failure to supply adequate calories and protein leads to malnutrition and delayed healing.

When teaching the patient about the use of range-of-motion (ROM), what explanations should the nurse give to the patient? (select all that apply)? a. the exercises are the only way to prevent contractures b. active and passive ROM maintain function of body parts c. ROM will show the patient that movement is still possible d. movement facilitates mobilization of leaked exudates back into the vascular bed. e. active and passive ROM can only be done while the dressings are being changed

b, c Active and passive ROM maintains function of body parts and reassures the patient that movement is still possible are the explanations that should be used. Contractures are prevented with ROM as well as splints. Movement facilitates mobilization of fluid in interstitial fluid back into the vascular bed. Although it is good to collaborate with physical therapy to perform ROM during dressing changes because the patient has already taken analgesics, ROM can and should be done throughout the day.

A patient with a burn inhalation injury is receiving albuterol (Ventolin) for bronchospasm. What is the most important adverse effect of this medication for the nurse to manage? a. GI distress b. tachycardia c. restlessness d. hypokalemia

b. Albuterol (Ventolin) stimulates β-adrenergic receptors in the lungs to cause bronchodilation. However, it is a non-cardioselective agent so it also stimulates the β-receptors in the heart to increase the heart rate. Restlessness and GI upset may occur but will decrease with use. Hypokalemia does not occur with albuterol.

The patient received a cultured epithelial autograft (CEA) to the entire left leg. What should the nurse include in the discharge teaching for this patient? a. sit or lay in the position of comfort b. wear a pressure garment for 8 hours each day c. refer the patient to a counselor for phychosocial support d. use the sun to increase the skin color on the healed areas

c. In the rehabilitation phase, the patient will work toward resuming a functional role in society, but frequently there are body image concerns and grieving for the loss of the way they looked and functioned before the burn, so continued counseling helps the patient in this phase as well. Putting the leg in the position of comfort is more likely to lead to contractures than to help the patient. If a pressure garment is prescribed, it is used for 24 hours per day for as long as 12 to 18 months. Sunlight should be avoided to prevent injury, and sunscreen should always be worn when the patient is outside.

Which patient is most appropriate for the burn unit charge nurse to assign to a registered nurse (RN) who has floated from the hospital medical unit? a. A 34-year-old patient who has a weight loss of 15% from admission and requires enteral feedings. b. A 67-year-old patient who has blebs under an autograft on the thigh and has an order for bleb aspiration c. A 46-year-old patient who has just come back to the unit after having a cultured epithelial autograft to the chest d. A 65-year-old patient who has twice-daily burn debridements and dressing changes to partial-thickness facial burns

ANS: A An RN from a medical unit would be familiar with malnutrition and with administration and evaluation of response to enteral feedings. The other patients require burn assessment and care that is more appropriate for staff who regularly care for burned patients.

A nurse cares for a client with burn injuries. Which intervention should the nurse implement to appropriately reduce the client's pain? a. Administer the prescribed intravenous morphine sulfate. b. Apply ice to skin around the burn wound for 20 minutes. c. Administer prescribed intramuscular ketorolac (Toradol). d. Decrease tactile stimulation near the burn injuries.

ANS: A Drug therapy for pain management requires opioid and nonopioid analgesics. The IV route is used because of problems with absorption from the muscle and the stomach. For the client to avoid shivering, the room must be kept warm, and ice should not be used. Ice would decrease blood flow to the area. Tactile stimulation can be used for pain management.

During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion? a. Check skin turgor. b. Monitor daily weight. c. Assess mucous membranes. d. Measure hourly urine output.

ANS: D When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hour. The patient's weight is not useful in this situation because of the effects of third spacing and evaporative fluid loss. Mucous membrane assessment and skin turgor also may be used, but they are not as adequate in determining that fluid infusions are maintaining adequate perfusion.

The nursing instructor is teaching about the emergent/resuscitative phase of burn injury. During this phase, what would the nursing instructor tell the students they should closely monitor in the laboratory values? A) Sodium deficit B) Bleeding time C) Potassium deficit D) Decreased hematocrit

Answer: A Rationale: Anticipated fluid and electrolyte changes that occur during the emergent/resuscitative phase of burn injury include potassium excess, sodium deficit, base-bicarbonate deficit, and elevated hematocrit.

A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. What would be the nurse's priority concern about this patient? A) Fluid status B) Risk of infection C) Body image D) Level of pain

Answer: A Rationale: During the early phase of burn care, the nurse is most concerned with fluid resuscitation, to correct large-volume fluid loss through the damaged skin. Infection, body image, and pain are significant areas of concern, but are less urgent than fluid status.

The nursing students are doing clinical hours on the burn unit. A nurse is developing a care plan for a patient with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. A nursing student asks why this goal is important when the patient is fighting for his life. What should the burn nurse respond? A) To prevent neuropathies B) To prevent wound breakdown C) To prevent contractures D) To prevent heterotopic ossification

Answer: C Rationale: To prevent the complication of contractures the nurse will establish a goal to maintain position of joints in alignment. Gentle range of motion exercises and a consult to PT and OT for exercises and positioning recommendations are also appropriate interventions for the prevention of contractures.

When teaching the patient about the use of range-of-motion (ROM), what explanations should the nurse give to the patient? Select all that apply. A. The exercises are the only way to prevent contractures. B. Active and passive ROM maintain function of body parts. C. ROM will show the patient that movement is still possible. D. Movement facilitates mobilization of leaked exudates back into the vascular bed. E. Active and passive ROM can only be done while the dressings are being changed.

B, C. Active and passive ROM maintains function of body parts and reassures the patient that movement is still possible are the explanations that should be used. Contractures are prevented with ROM as well as splints. Movement facilitates mobilization of fluid in interstitial fluid back into the vascular bed. Although it is good to collaborate with physical therapy to perform ROM during dressing changes because the patient has already taken analgesics, ROM can and should be done throughout the day.

The nurse is caring for a patient with superficial partial-thickness burns of the face sustained within the last 12 hours. Upon assessment the nurse would expect to find which manifestation? A. Blisters B. Reddening of the skin C. Destruction of all skin layers D. Damage to sebaceous glands

B. Reddening of the skin The clinical appearance of superficial partial-thickness burns includes erythema, blanching with pressure, and pain and minimal swelling with no vesicles or blistering during the first 24 hours.

The patient in the acute phase of burn care has electrical burns on the left side of her body, type 2 diabetes mellitus, and a serum glucose level of 485 mg/dL. What should be the nurse's priority intervention to prevent a life-threatening complication of hyperglycemia for this burned patient? A. Replace the blood lost. B. Maintain a neutral pH. C. Maintain fluid balance. D. Replace serum potassium.

C. Maintain fluid balance. This patient is most likely experiencing hyperosmolar hyperglycemic syndrome (HHS). HHS dehydrates a patient rapidly. Thus HHS combined with the massive fluid losses of a burn tremendously increase this patient's risk for hypovolemic shock and serious hypotension. This is clearly the nurse's priority because the nurse must keep up with the patient's fluid requirements to prevent circulatory collapse caused by low intravascular volume. There is no mention of blood loss. Fluid resuscitation will help to correct the pH and serum potassium abnormalities.

The patient received a cultured epithelial autograft (CEA) to the entire left leg. What should the nurse include in the discharge teaching for this patient? A. Sit or lay in the position of comfort. B. Wear a pressure garment for 8 hours each day. C. Refer the patient to a counselor for psychosocial support. D. Use the sun to increase the skin color on the healed areas.

C. Refer the patient to a counselor for psychosocial support. In the rehabilitation phase, the patient will work toward resuming a functional role in society, but frequently there are body image concerns and grieving for the loss of the way they looked and functioned before the burn, so continued counseling helps the patient in this phase as well. Putting the leg in the position of comfort is more likely to lead to contractures than to help the patient. If a pressure garment is prescribed, it is used for 24 hours per day for as long as 12 to 18 months. Sunlight should be avoided to prevent injury, and sunscreen should always be worn when the patient is outside.

The ambulance reports that they are transporting a patient to the ED who has experienced a full-thickness thermal burn from a grill. What manifestations should the nurse expect? A. Severe pain, blisters, and blanching with pressure B. Pain, minimal edema, and blanching with pressure C. Redness, evidence of inhalation injury, and charred skin D. No pain, waxy white skin, and no blanching with pressure

D. No pain, waxy white skin, and no blanching with pressure With full-thickness burns, the nerves and vasculature in the dermis are destroyed so there is no pain, the tissue is dry and waxy-looking or may be charred, and there is no blanching with pressure. Severe pain, blisters, and blanching occur with partial-thickness (deep, second-degree) burns. Pain, minimal edema, blanching, and redness occur with partial-thickness (superficial, first-degree) burns.

A nurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. Which action should the nurse take next? a. Administer furosemide (Lasix). b. Perform chest physiotherapy. c. Document and reassess in an hour. d. Place the client in an upright position.

d. Place the client in an upright position. ANS: D Pulmonary edema can result from fluid resuscitation given for burn treatment. This can occur even in a young healthy person. Placing the client in an upright position can relieve lung congestion immediately before other measures can be carried out. Although Lasix may be used to treat pulmonary edema in clients who are fluid overloaded, a client with a burn injury will lose a significant amount of fluid through the broken skin; therefore, Lasix would not be appropriate. Chest physiotherapy will not get rid of fluid.