IGGY Burns

The nurse is caring for a patient with 45% total body surface area (TBSA) burns. Which are priority medical surgical concepts for this patient? 1- Tissue integrity 2- Cellular regulation 3- Perfusion 4- Elimination 5- Fluid and electrolyte balance 6- Gas exchange

1- Tissue integrity 3- Perfusion 5- Fluid and electrolyte balance

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

b. Acute kidney injury

The home health nurse is visiting an older couple for the initital visit. In observing the household, the nurse identifies several behaviors and environmental factors to address. Which identified factors increase the risk for burns and/or household fires? SELECT ALL THAT APPLY A- Several potholders hanging within easy reach of the stove B- Ashtray with old cigarette butts on the bedside table C- Space heater very close to the bed D- SIngle smoke detector in the kitchen E- Back exit hall of the house used as a storage space F- Small throw rug near the front door

B- Ashtray with old cigarette butts on the bedside table C- Space heater very close to the bed D- SIngle smoke detector in the kitchen E- Back exit hall of the house used as a storage space

The physician has ordered an escharotomy for a patient because of constriction around the patient's chest. The nurse is teaching the patient and family about the procedure. Which statement by the family indicates a need for additional teaching? a. "He will have to receive general anesthesia." b. "He'll be awake for the procedure." c. "He will receive medication for sedation and pain." d. "We could stay with him at the bedside during the procedure."

a. "He will have to receive general anesthesia."

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

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

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

b. Acute kidney injury

The nurse is assessing a patient with a burn wound to the back and chest area. Which assessment findings are consistent with a superficial-thickness burn wound? (Select all that apply.) a. Pink to red b. Pain c. Mild edema d. Moisture e. Eschar f. Blanch to pressure

a. Pink to red b. Pain c. Mild edema f. Blanch to pressure

Which are expected outcomes when evaluating the care of a patient with burn injuries? SELECT ALL THAT APPLY a. Pts infection was treated rapidly b. Pts airway remained patent c. Pts pain was decreased or relieved d. Pts perception of self is positive e. Pts weight loss was only 10% f. Pts wounds are all in the process of healing

b. Pts airway remained patent c. Pts pain was decreased or relieved d. Pts perception of self is positive

The nurse is caring for several patients who have sustained burns. The patients with which initial injury is the least likely to experience severe pain when a sharp stimulus is applied? a. severe sunburn after lying in the sun for several hours b. deep full-thickness burn from an electrical accident c. partial-thickness burn from picking up a hot pan d. deep partial-thickness burn after a motorcycle accident

b. deep full-thickness burn from an electrical accident

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

c. Increased caloric needs

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

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

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

c. Massaging nonburned areas

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

c. Patient will report a headache.

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

c. Playing music in the background d. Use of meditative breathing e. Use of guided imagery f. Providing healing or therapeutic touch

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

c. Preburn weight

The nurse is performing a morning assessment on a patient admitted for a serious burns to the extremities. For what reason does the nurse assess the patient's abdmomen? a. perform head to toe assessment b. assess for nausea and vomiting r/t pain medication c. assess for paralytic ileus secondary to reduced blood flow d. monitor increased motility that may result in cramps and diarrhea

c. assess for paralytic ileus secondary to reduced blood flow

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

d. 77 year old man

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

c. Electrical burn and myoglobin in the urine

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

c. Full-thickness

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

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

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

a. Anemia

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

a. Dorsiflexion

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

a. Sickle cell for trait

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

b. Intubation

The nurse is caring for a firefighter who was trapped for a prolonged period of time by burning debris. During the shift, the nurse notes a progressive hoarseness, a brassy cough, and the patient reports increased difficulty with swallowing. How does the nurse interpret these changes? a. Temporary discomfort that can be treated with sips of cool fluids b. Signs and symptoms of probable carbon monoxide poisoning c. Signs indicating a pulmonary injury and possible airway obstruction d. Expected findings considering the mecha- nism of injury

c. Signs indicating a pulmonary injury and possible airway obstruction

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

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

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

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

A patient was involved in a house fire and suffered full-thickness burns. In the long-term, what issue may this patient have trouble with? a. intolerance for vitamin C b. metabolism of vitamin K c. activation of vitamin D d. absorption of vitamin A

c. activation of vitamin D

A patient with a burn injury had an autograft. The nurse learns in report that the donor site is on the upper thigh. What type of wound does the nurse expect to find at donor site? a. Stage 1 b. Partial-thickness c. Full-thickness d. Stage 4

b. Partial-thickness

The nurse is changing a burn patients dressing. Which factors would affect the # of gauze layers applied after a topical agent has been applied to treat the wound? SELECT ALL THAT APPLY a. Amount of drainage b. Patient mobility c. Amount of pain d. Depth of injury e. Positioning of patient f. Frequency of dressing changes

a. Amount of drainage b. Patient mobility d. Depth of injury f. Frequency of dressing changes

28-year-old male patient sustained second- and third-degree burns on his legs (30%) when his clothing caught fire while he was burning leaves. He was hosed down by his neighbor and has arrived at the ED in severe discomfort. What is the priority problem for this patient at this time? a. Acute pain related to damaged or exposed nerve endings b. Decreased fluid volume related to electrolyte imbalance c. Potential for inadequate oxygenation d. Diminished self-image related to the appearance of legs

a. Acute pain related to damaged or exposed nerve endings

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

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

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

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

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

a. Discussing the possibility of reconstructive surgery with the patient

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

a. Exercise the hand, thumb, and fingers every hour while awake.

What does the process of full-thickness wound healing include? (Select all that apply.) a. Healing occurs by wound contraction. b. Eschar must be removed. c. Large blisters are protective and left undisturbed. d. Skin grafting may be necessary. e. Fasciotomy may be needed to relieve pressure and allow normal blood flow. f. Complete healing occurs within 3-6 weeks

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

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

a. Hyperkalemia d. Hyponatremia

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

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

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

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

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

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

The nurse is caring for a burn patient who was stabilized by and transferred from a small rural hospital. The patient develops a new complaint of shortness of breath. On auscultation, the nurse hears crackles throughout the lung fields. What does the nurse suspect is causing this patient's symptoms? a. Pulmonary fluid overload due to fluid resuscitation b. Exposure to carbon monoxide that was undiagnosed c. Fat emboli secondary to extensive injury d. Excessive oxygen therapy at the first facility

a. Pulmonary fluid overload due to fluid resuscitation

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

a. Recognize an impending airway obstruction and prepare for immediate intubation

The nursing student notes on the care plan that the burn patient she is caring for is at risk for organ ischemia. Based on the student's knowledge of the pathophysiology of burns, which etiology does the nursing student select? a. Related to hypovolemia and myoglobin release b. Related to fluid overload and peripheral edema c. Related to prolonged resuscitation and hypoxia d. Related to direct blunt trauma to the kidneys

a. Related to hypovolemia and myoglobin release

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

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

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

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

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

a. Skin epidermis

WHich factors in the older adult increase the risk of complications from a burn injury? SELECT ALL THAT APPLY a. Slower healing time b. Thinner skin c. Increased inflammatory response d. Increased pulmonary compliance e. Altered glucose metabolism f. History of heart failure

a. Slower healing time b. Thinner skin e. Altered glucose metabolism f. History of heart failure

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

a. The airway

The nurse is reviewing the hgb and hct results for a patient recently admitted for a severe burn. Which result is most likely r/t vascular dehydration? a. hct of 58% b. hgb of 14 c. hct of 42% d. hgb of 10

a. hct of 58%

A patient was burned on the forearm after tripping and falling against a wood burning stove. There are currently several small blisters over the burn area. What does the nurse advise the patient to do about the blisters? a. leave the blisters intact bc they protect the wound from infection b. use a sterile needle to open a tiny hole in each blister to drain the fluid c. allow blisters to increase in size; then open them to prevent immunosuppression d. leave the blisters intact unless the pain and pressure increase.

a. leave the blisters intact bc they protect the wound from infection

The nurse is caring for a young woman who sustained burns on the upper extremities and anterior chest while attempting to put out a kitchen grease fire. Which laboratory results does the nurse expect to see during the resuscitation phase? (Select all that apply.) a Potassium level of 3.2 mEq/L b Glucose level of 180 mg/dL c Hematocrit of 49% d pH of 7.20 e. Sodium level of 139 mEq/L f. Albumin level 2.9

b Glucose level of 180 mg/dL c Hematocrit of 49% d pH of 7.20 f. Albumin level 2.9

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

b. Adult whose weight is proportionate to height

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

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

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

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

A patient is transported to the ED for severe and extensive burns that occurred while he was trapped in a burning building. The patient is severely injured with respiratory distress and the resuscitation team must immediately begin multiple interventions. Which task is delegated to unlicensed assistive personnel (UAP)? a. Position the patient's head to open the airway and assist with intubation. b. Assist the respiratory therapist to maintain a seal during bag-valve-mask ventilation. c. Prepare the intubation equipment and set up the oxygen flowmeter. d. Elevate the head of the bed to achieve a high-Fowler's position.

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

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

b. Blanching

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

b. Depressed up to 36 hours after the burn

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

b. Desquamation

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

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

To prevent the complications of Currlings ulcer, what does the nurse anticipate the HCP will order? a. NG tube insertion b. Histamine-2 blockers c. Abdominal assessment Q4 hrs d. Systemic ABX

b. Histamine-2 blockers

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

b. It is a leak of plasma fluids into the interstitial space.

The nurse is providing care for a burn patient who recently received a graft. On assessment of the wound, redness and swelling as well as some foul smelling drainage is noted. What does the nurse suspect? a. Partial thickness burn b. Local infection of burn wound c. Failure of the graft d. Systemic sepsis

b. Local infection of burn wound

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

b. Metabolic acidosis

The nurse is caring for a burn patient who received rigorous fluid resuscitation in the ED for hypotension and hypovolemic shock. In assessing renal function for the first 24 hours, what finding does the nurse anticipate? a. Output will be approximately equal to fluid intake. b. Output will be decreased compared to fluid intake. c. Urine will have a very low specific gravity and a pale-yellow color. d. Output will be managed with diuretic

b. Output will be decreased compared to fluid intake.

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

b. Place a new disposable stethoscope in the room.

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

b. Prevent sepsis

What feelings are most typically expressed by the burn patient? SELECT ALL THAT APPLY a. Suspicion b. Regression c. Apathy d. Denial e. Suicidal ideations f. Anger

b. Regression d. Denial f. Anger

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

b. Secure the airway

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

b. Tetanus

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

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

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

b. Vital signs and airway assessment every shift

A burn patient must have pressure dressings applied to prevent contractures and reduce scarring. For maximum effectiveness, what procedure pertaining to the pressure garments is implemented? a. Changed every 24 to 48 hours to prevent infection b. Worn at least 23 hours a day until the scar tissue matures c. Removed for hygiene and during sleeping d. Applied with aseptic technique

b. Worn at least 23 hours a day until the scar tissue matures

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

c. "Can you tell me about what has been happening since you were discharged from the hospital?"

An adult patient is admitted to the burn unit after being burned in a house fire. Assessment reveals burns to the entire face, back of the head, anterior torso, and circumferential burns to both arms. Using the rule of nines, what is the extent of the burn injury? a. 18% b. 24% c. 45% d. 54%

c. 45%

At what point does fluid mobilization occur in patients with burns? a. After the scar tissue is formed and fluids are no longer being lost. b. Within the first 4 hours after the burns were sustained. c. After 24 hours when the fluid is reabsorbed from the interstitial tissue. d. Immediately after the burns occur

c. After 24 hours when the fluid is reabsorbed from the interstitial tissue.

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

c. Carboxyhemoglobin level

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

c. Cherry-red skin color

Over a period of 4 days a patient developed an elevated temperature associated with disorientation and lethargy. Lab values include normal platelets. Which type of infection does the nurse expect? a. Viral b. Fungal c. Gram-positive d. Gram-negative

c. Gram-positive

The nurse is caring for a patient who has 30% burns. During the first 12 to 36 hours, the nurse carefully monitors the patient for which status changes r/t capillary leak syndrome? a. bradycardia and pitting edema b. HTN and decreased UOP c. tachycardia and hypotension d. resp depression and lung crackles

c. tachycardia and hypotension

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

d. 5000

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

d. Deep full-thickness

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

d. Encourage visits from friends and short public appearances before discharge

A patient has severe burns to the anterior surface of the body from a short exposure to high temperatures at a work-site furnace. Which area of the body is most vulnerable to a deep burn injury? a. Anterior chest b. Upper arms c. Palmer surface of hands d. Eyelids

d. Eyelids

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

d. Hypovolemic shock

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

d. Performing hand hygiene correctly and when appropriate

A burn patient refuses to eat. The potential problem of weight loss related to increased metabolic rate and reduced calorie intake is identified for this patient. What method does the nurse use to correctly weigh this patient? a. Weigh once a week after morning hygiene and compare to previous weight. b. Weigh daily at the same time of day and compare to preburn weight. c. Use a bed scale and subtract the estimated weight of linens. d. Weigh daily without dressings or splints and compare to preburn weigh

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

The nurse is interviewing and assessing an electrician who was brought to the ED after being electrocuted. The patient is currently alert with no respiratory distress. During the interview, what does the nurse assess for? a. knowledge of electrical safety b. burn marks on the dominant hand c. injuries based on the report of pain d. entrance and exit wounds

d. entrance and exit wounds

The nurse is caring for several patients on the burn unit who have sustained extensive tissue damage. The nurse should monitor for which electrolyte imbalance that is typically associated with the initial 3rd-spacing fluid shift? a. hypercalcemia b. hypernatremia c. hypokalemia d. hyperkalemia

d. hyperkalemia