Elsevier Ch 24

A nurse is teaching a group of parents how to reduce the risk for injury related to burns. Which statement by a participant indicates effective learning?

"I should hold regular home fire exit drills."

Which statement made by a student nurse regarding clinical manifestations associated with severe burns indicates the need for further education?

"The patient is unconscious and cannot answer until intubated."

Which structure of the skin is affected in a deep partial-thickness burn?

1

Fluid resuscitation is an important intervention in burn patients. The nurse recognizes that what fluid is recommended for the first 24 hours after a burn?

2 to 4 mL lactated Ringer's/kg/%TBSA burned

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?

22.5%

When attending to a patient with severe burns, what precautions should the nurse take to maintain adequate nutrition? Select all that apply.

Assess bowel sounds every eight hours. Begin early enteral feeding with smaller-bore tubes. Begin the feedings slowly at a rate of 20 to 40 mL/hr.

A young patient who experienced burns on the neck and chest from a fire at the workplace two hours ago presents to the emergency department (ED). The patient is not intubated and on assessment the nurse suspects inhalation injury. What appropriate actions should the nurse perform? Select all that apply.

Assist in performing a fiberoptic bronchoscopy. Reposition the patient every one to two hours. Encourage deep breathing and coughing every hour.

It is essential to check the patient for allergies to sulfa.Silver-impregnated dressings can be left in place from 3 to 14 days.Topical antimicrobial agents may be applied after the wound cleansing.

It is essential to check the patient for allergies to sulfa. Silver-impregnated dressings can be left in place from 3 to 14 days. Topical antimicrobial agents may be applied after the wound cleansing.

A nurse is providing care to a patient with an electrical burn injury. The patient is experiencing premature ventricular contractions (PVCs) and laboratory tests indicate the presence of myoglobinuria. For which complication will the nurse monitor?

Acute tubular necrosis (ATN)

A patient sustains burns covering 35% of the body surface area. The patient weighs 100 kg. Which action is most appropriate for the nurse to take during the early course of the patient's care?

Administering 7000 mL of crystalloid IV fluids over the 8 hours after injury

A patient is admitted to the burn center with burns of the face, upper chest, and hands after fireworks exploded in the patient's garage, catching the patient's shirt on fire. On assessment, the nurse notes that the patient is coughing up black sputum, has singed nasal hair, darkened oral and nasal membranes, and smoky breath with increasing shortness of breath and hoarseness. Which of these actions would be the most appropriate for the nurse to take next?

Anticipate the need for endotracheal intubation and notify the health care provider.

A patient has sustained thermal injuries amounting to approximately 30% of his or her total body surface area. What action should the nurse take first?

Check for a patent airway, breathing, and circulation.

A patient with burns of more than 5% of the total body surface area is intubated, and enteral feedings are ordered to meet nutritional demands. Which nursing interventions are appropriate for the enteral feeding of this patient? Select all that apply.

Check gastric residuals frequently. Assess bowel sounds every eight hours. Determine whether the nasogastric tube is in place. Increase the feeding to the goal rate within 24 to 48 hours.

A patient has thermal burns on the face, including the cheeks and the area around the eyes. Which action would the nurse take?

Cover the face with ointment and gauze.

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.

Daily cleansing and debridement Application of topical antimicrobial agent Intravenous (IV) and oral pain medications Escharotomy

The nurse collaborates with the health care team regarding the treatment of partial-thickness second-degree burn to the chest, abdomen, and both anterior thighs sustained by a patient. Which treatment does the nurse recognize as appropriate and within the scope of nursing practice?

Daily wound cleaning with debridement and sterile dressing changes

A nurse is providing care to a patient with a partial-thickness burn. Which clinical manifestation does the nurse anticipate?

Damage to epidermis and dermis involving varying depths

A nurse notes decreased reflexes during the physical assessment of a patient who was admitted with a burn injury. What is the likely cause for this clinical manifestation?

Decreased potassium levels

A patient with a flash burn injury is admitted to the emergency department. The nurse notes a bright red area with blisters that blanches with the application of pressure. The patient also reports severe pain when the burn is exposed to air. Which type of burn is present?

Deep partial-thickness burn

A nurse is instructing a patient about the immediate steps that need to be taken in the case of electrical burns. What precautions should the nurse instruct as necessary to perform? Select all that apply

Do not cover the burned part with ice. Do not immerse the burned part in cool water Cool large burns for not more than 10 minutes

What are the clinical manifestations of a lower airway lung injury associated with burns? Select all that apply.

Dyspnea wheezing Altered mental status

A patient with severe electric burns is admitted to the burn unit. When assessing the patient, what symptoms does the nurse know would indicate this patient is hyperkalemic? Select all that apply.

ECG changes Muscle weakness Cardiac dysrhythmias

A patient with a burn injury is brought to the emergency department. The nurse notes white, leathery skin, dysrhythmias, and a loss of consciousness. Which type of burn injury does the nurse suspect?

Electrical

A patient sustains a second-degree (partial-thickness) burn. Which layer(s) of skin does the nurse inspect for damage?

Epidermis and dermis

A patient arrives in the burn unit with erythema, pain, and mild swelling following a burn injury while cooking. Based on the wound observation and patient symptoms, the nurse should document the depth of the burn as what?

First degree

Which type of burn injury occurs on the layers of subcutaneous fat, muscle, or deeper structures?

Full thickness burn

Which type of burn injury is depicted in the image?

Full-thickness scald burn

A patient with a hand burn, depicted in the image, is admitted to the burn trauma center. Which type of burn does the nurse suspect based on this data?

Full-thickness thermal hand burn

A nurse is providing care to a patient who was admitted to the hospital with third-degree burns. Which clinical manifestations should the nurse anticipate? Select all that apply.

Hard, leathery skin Insensitivity to pain

A nurse is triaging a patient who has arrived in the emergency department with burns as a result of a fire. Which patient symptoms indicate an upper airway injury? Select all that apply.

Hoarseness Difficulty swallowing Copious secretions

Which complications occur in a patient with metabolic asphyxiation? Select all that apply.

Hypoxia Hydrogen Cyanide Poisoning

A nurse is teaching a patient's caregivers about the immediate action to be taken in case of burns of more than 10% of body surface area. What reasons does the nurse provide for avoiding the use of ice on the burned body part? Select all that apply.

Ice can cause hypothermia. Ice can cause vasoconstriction. Ice can reduce blood flow to the burned area

A nurse is providing care to a patient admitted to the burn unit. Which pathophysiologic changes does the nurse anticipate in this patient? Select all that apply.

Increased Viscosity Decreased blood volume Increased vascular permeability

When assessing a patient suffering from inhalation burns on the face and chest, what findings should a nurse anticipate? Select all that apply.

Increasing hoarseness Darkened oral or nasal membranes Productive cough with black sputum

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 accidentally burned in the new home?

Install tap water anti-scald devices

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?

Intravenous (IV) morphine sulfate

A nurse is assessing a patient who was injured using heavy industrial cleanser while working at a factory. For which complications will the nurse monitor? Select all that apply.

Liquefaction Protein hydrolysis

A burn patient is about to receive a dressing change. The patient has dressings over both feet and lower legs and is receiving a continuous infusion of hydromorphone. Which medication(s) is/are appropriate for the patient to receive before the dressing change is started? Select all that apply.

Lorazepam, an anxiolytic Intravenous fentanyl, a short-acting opioid

A patient who escaped from a burning building, which was enclosed with no ventilation, is brought to the emergency department. The patient is confused, has difficulty breathing, and has nasal burns. Which condition does the nurse suspect?

Lower airway injury

The patient in the acute phase of burn care has electrical burns on the left side of the body, type 2 diabetes mellitus, and a serum glucose level of 485 mg/dL. What should be the nurse's priorityintervention to prevent a life-threatening complication of hyperglycemia for this burned patient?

Maintain fluid balance

A patient with partial-thickness burns is now allowed oral feedings. What nursing interventions should the nurse perform to maintain the patient's nutrition? Select all that apply.

Suggest a high-protein diet. Suggest a high-carbohydrate diet. Ask caregivers to get the patient's favorite food

Which complication is caused by an electric burn?

Myoglobinuria

An unconscious patient who suffered an electrical burn is admitted to the emergency department. For which complications will the nurse monitor? Select all that apply.

Myoglobinuria Cervical spine injury Severe metabolic acidosis

The ambulance reports that it is transporting a patient to the emergency department who has experienced a full-thickness thermal burn from a grill. What manifestations should the nurse expect?

No pain, waxy white skin, and no blanching with pressure

A patient is brought to the emergency department (ED) with a history of inhalation burn injury. The patient has also sustained burns on the face, neck, and hands. Which actions would the nurse perform immediately? Select all that apply.

Provide 100% humidified oxygen. Observe for signs of respiratory distress. Check for evidence of inhalation of smoke.

A patient who had a burn injury two days ago over 35% of the body is in the intensive care unit. The patient is intubated, on a mechanical ventilator, and fluid status is stable. Which of these interventions will the nurse anticipate for the patient's nutrition?

Provide enteral tube feeding, starting at 20 mL/hour.

A nurse is preparing a patient with partial-thickness burns on the hands for discharge from the burn care unit. What instructions should the nurse include when teaching the patient about rehabilitation at home? Select all that apply.

Recommend exercises. Take low-dose antihistamines. Do not apply any creams on the wounds. Apply water-based creams on healed areas.

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?

Refer the patient to a counselor for psychosocial support

For which clinical manifestations should the nurse monitor a burn-injured client with hypernatremia after successful fluid resuscitation? Select all that apply.

Seizures Hypertension

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 the nurse to the presence of an inhalation injury? Select all that apply.

Singed nasal hair Increasing hoarseness Painful swallowing History of being trapped in an enclosed space

A patient is brought to the emergency department (ED) with severe burns on the legs and feet. Which factors lead the nurse to believe the patient may have full-thickness burns? Select all that apply.

Touch sensation is impaired. Lack of blanching with pressure is observed. Wounds appear waxy white, dark brown, or charred.

A nurse is involved in the wound care of patients on the burn management unit. What precautions should the nurse take while performing wound care? Select all that apply.

The nurse wears personal protective equipment. The nurse uses sterile gloves when applying sterile dressings. The nurse uses nonsterile gloves when removing contaminated dressings.

A patient who sustained burn injuries is receiving daily treatments. The patient tells the caregiver, "The nurses enjoy hurting me." What should the nurse suspect? Choose the best answer.

This is a normal reaction to an extraordinary life event.

While caring for a patient with burns, a nurse wraps the patient's wound with tubular elastic gauze. What are the reasons behind this action? Select all that apply.

To decrease pain To prevent blistering To decrease itchiness

Why does the nurse apply enzymatic debriding agents to a patient with severe wounds?

To remove dead tissue from the healthy wound bed

A patient presents with scalding burns on the chest and abdomen. On examination, the nurse suspects that the patient has superficial partial-thickness burns. What findings would the nurse expect to find? Select all that apply.

Wounds are red and painful. There is blanching with pressure. The burned area has minimal edema.

When instructing a patient's caregiver about caring for a person with burns of more than 10% of total body surface area (TBSA), what does the nurse advise? Select all that apply.

Wrap the patient in a blanket. Gently remove burned clothing. Leave adherent clothing in place.