BSSM
Which of the following signs would be most indicative of distributive shock? A.Strong, rapid pulse B.Cold, clammy skin C.Decreased urinary output D.Warm, flushed skin
D.Warm, flushed skin
Jimmy has a partial thickness burn on his upper chest and soot nares. What is the primary intervention? a. Flush his nostrils b. Apply oxygen & prepare for ET tube c. Start CPR d. Auscultate his lungs
b. Apply oxygen & prepare for ET tube
How do you treat carbon monoxide poisoning? a. Put patient in high fowlers b. Give 0.9% normal saline c. Remove carbon monoxide d. Apply 100% humidified oxygen
d. Apply 100% humidified oxygen
Which patient should be transferred to a burn center? SATA a.ICE b. Burns and concomitant trauma c.Full thickness burn any age d. 2nd degree burns with vesicles e. Partial thickness burns
a.ICE b. Burns and concomitant trauma c.Full thickness burn any age
A client presents to the emergency department following a burn injury. The client has burns to the abdomen and front of the left leg. Using the rule of nines, the nurse documents the total body surface area percentage as a. 36% b. 27% c. 18% d. 9% e. 22.5%
b. 27%
The nurse is teaching a client who underwent a skin graft for a burn injury about the use of pressure garments. What instruction(s) should the nurse include in the teaching? SATA a. Wear the garment at least 12 hours each day. b. Contact the primary care provider if the garment does not seem to fit properly. c. Machine wash the pressure garment daily with a mild detergent. d. Roll the garment and wring tightly to ensure garment is as dry as possible after washing. e. Massage any moisturizers, lotions, creams, and petroleum-based ointments completely into the skin before donning the garment.
b. Contact the primary care provider if the garment does not seem to fit properly. e. Massage any moisturizers, lotions, creams, and petroleum-based ointments completely into the skin before donning the garment.
The nurse recognizes what as an early sign of sepsis in a client with a burn injury? a. Normal body temperature b. Decreased heart rate c. Elevated serum glucose d. Widened pulse pressure
c. Elevated serum glucose
A 6 year old patient comes to the ER and has been in a house fire. She has 6% TBSA 2nd degree burns. What is the priority intervention? a. apply ice to the area of burn b. wipe areas of blister vigorously to clean the wound c. apply a clean, cool, tap water damp towel d. apply petroleum jelly to the burn
c. apply a clean, cool, tap water damp towel
You are a nurse on a Med Surg unit assigned to a patient who was involved in a house fire 36 hours ago. They are having trouble breathing. Upon auscultation, you hear crackles. What are you concerned about? a. URI b. pneumonia c. CHF exacerbation d. ARDS
d. ARDS
A nurse is caring for a patient who has burns of the ears, head, neck, and right arm and hand. The nurse should place the patient in which position? A)Place the right arm and hand flexed in a position of comfort B)Elevate the right arm and hand on pillows and extend the fingers C)Assist the patient to a supine position with a small pillow under the head D)Position the patient in a side-lying position with a rolled towel under the neck
B)Elevate the right arm and hand on pillows and extend the fingers
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 patient to cough and auscultate again B)Notify health care provider ASAP C)Document the results and continue to monitor respiratory rate D)Reposition the patient in high-fowlers and reassess breath sounds
B)Notify health care provider ASAP
Why is Lactated Ringer's (LR) solution considered a suitable fluid choice for initial resuscitation in a patient with sepsis-induced hypovolemic shock? A. It provides immediate inotropic support to the heart. B. It corrects acid-base imbalances by metabolizing lactate to bicarbonate. C. It acts as a vasopressor to counteract the vasodilation present in sepsis. D. It replenishes intracellular electrolytes directly. B. It corrects acid-base imbalances by metabolizing lactate to bicarbonate.
B. It corrects acid-base imbalances by metabolizing lactate to bicarbonate.
When a patient presents with shock and is found to have a heart attack, what type of shock should be suspected primarily? A.Hypovolemic shock B.Cardiogenic shock C.Distributive shock D.Obstructive shock
B.Cardiogenic shock
What types of pain do burn patients have? (SATA) A.Bone pain B.Continuous background pain C.Rectal pain D.Treatment induced pain E.Emotional pain
B.Continuous background pain D.Treatment induced pain
What could a nurse expect to see if a patient is diagnosed with obstructive shock? SATA A.Increased venous return B.Decreased stroke volume C.Decreased cardiac output D.Increased cellular supply E.Decreased tissue perfusion
B.Decreased stroke volume C.Decreased cardiac output E.Decreased tissue perfusion
A patient is brought to the ED from the site of a chemical fire, where the patient suffered a burn that involves the epidermis and the dermis of the right hand. On assessment, the skin appears to have a wet, waxy red to pale skin that does not blanch. What is the depth of this burn? SATA A.Superficial partial thickness B.Deep partial thickness C.Full thickness D.1st degree E.2nd degree F.3rd degree
B.Deep partial thickness F.3rd degree
When is the best time for dressing changes: A.When toileting B.During ROM with PT/OT C.During bed bath D.When they are sleeping
B.During ROM with PT/OT
What are the signs and symptoms of septic shock? SATA A.Bradycardia B.Hyperlactatemia C.Leukocytosis or leukopenia D.Hyperthermia or hypothermia E.Increased capillary refill time
B.Hyperlactatemia C.Leukocytosis or leukopenia D.Hyperthermia or hypothermia
The nurse is caring for a patient who sustained a full thickness burn to his arm when he was scalded with boiling water. How did the nurse determine that the patient's burns are full thickness burns? A.Classification by the appearance of blisters B.Identification by the destruction of the dermis and epidermis C.Burn not associated with edema formation D.Usually very painful because of exposed nerve endings E.Skin blanches on touch F.Identification by the damage to the epidermis, but not the epidermis
B.Identification by the destruction of the dermis and epidermis
Which interventions are appropriate for a patient in cardiogenic shock? SATA A.Administration of intravenous fluids B.Inotropic support C.Immediate percutaneous coronary intervention (PCI) D.Vasodilators E.High-flow oxygen therapy
B.Inotropic support C.Immediate percutaneous coronary intervention (PCI) E.High-flow oxygen therapy
What is the primary goal for wound coverage? A.Hydration status B.Permanent/temporary skin coverage C.Infection prevention D.Reduce blood loss
B.Permanent/temporary skin coverage
The nursing that is caring for a patient with a superficial partial - thickness burn injuries to the lower extremities. The client is ordered IV morphine for pain. The nurse understands narcotics are given via IV during the initial management of pain because A.The client can experience nausea and emesis when given oral medications. B.Tissue edema may interfere with drug absorption via other routes. C.The pain resulting from a burn injury requires relief by the fastest route available. D.IV medications decrease the patient risk for tolerance and dependence.
B.Tissue edema may interfere with drug absorption via other routes.
SATA - SIRS criteria A.Respiration of 16 B.White blood cell count of 15,000 C.Heart rate of 110 D.Temperature of 98.6 E.PCO2 of 29
B.White blood cell count of 15,000 C.Heart rate of 110 E.PCO2 of 29
During the emergent phase of a burn the nurse should assess the urinary system because A: The kidneys give up easy. B: The patient is at risk for acute renal failure. C: The patient is at risk for urinary tract infection. D: The patient will be ashamed if they are incontinent of urine.
B: The patient is at risk for acute renal failure.
The patient is in the acute phase of a burn injury. The nurse noted eschar in the wound bed and compartment syndrome. What is the primary intervention for this patient? a. Document the finding b. Prepare patient for escharotomy c. Apply sterile moist dressing d. Attempt to scrape off that scar with scalpel
b. Prepare patient for escharotomy
A nurse is assessing a client who has experienced a burn and determines that the client has sustained a superficial burn. Which finding would support the nurse's determination? SATA a. Blistering b. Redness c. Pain d. Moist wound bed e. Mottling
b. Redness c. Pain
The nurse is caring for a client 48 hours after their burn injury. Which treatment will the nurse anticipate to reduce the client's risk of mortality? a. Administer IV ABX b. Remove burn tissue c. Regular bathing of burned areas d. Provide IV fluid therapy
b. Remove burn tissue
You've determined that your patient is experiencing ARDS. What is your primary intervention? a. obtain VS & stat ABG b. contact physician & anticipate need for ET intubation c. administer ABX d. encourage the patient to cough & deep breathe
b. contact physician & anticipate need for ET intubation
A student nurse is at the burn center and assigned to a patient with circumferential burns who is getting ready for an escharotomy? The student asks the nurse what a patient escharotomy is? a.Incision through the full thickness b.incisions in burned skin to release eschar, restore circulation, and allow ventilation c.Using gauze to cover the wound d. Irrigating with copious amount of water
b.incisions in burned skin to release eschar, restore circulation,and allow ventilation
A client requires a full-thickness graft to cover a chronic wound. How is the donor site selected? a. The largest area of the body without hair is selected. b. Any area that is not normally visible can be used. c. An area matching the color and texture of the skin at the surgical site is selected. d. An area matching the sensory capability of the skin at the surgical site is selected.
c. An area matching the color of the skin at the surgical site is selected.
A child tips a pot of boiling water onto his bare legs. The mother should a. Avoid touching the burned skin and take the child to the nearest ER. b. Cover the child's legs with ice cubes secured with a towel. c. Immerse the child's legs in cool water. d. Liberally apply butter or shortening to the burned areas.
c. Immerse the child's legs in cool water.
Patient presents to the ER with frostbite injury. Which of the following are correct interventions for this type of injury? a. Quickly rewarm the area of injury b. Drain all small blisters c. Rewarm affected area over 15 to 30 minutes d. Drain large clear blisters
c. Rewarm affected area over 15 to 30 minutes
The nurse is providing care for a patient who is showing signs and symptoms of shock. The nurse is choosing and prioritizing nursing interventions that are framed in the knowledge that the restoration of adequate tissue perfusion is essential to the patient's safe recovery. Tissue perfusion results from the interplay of which of the following essential factors? a. Homeostasis b. Balanced fluid intake & output c. Systemic vascular resistance d. Cardiac output e. Level of consciousness
c. Systemic vascular resistance d. Cardiac output
The nurse is caring for a patient with partial, 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. NPO c. High protein and low sodium foods d. High calorie and high protein foods
d. High calorie and high protein foods
The nurse cares for a client with superficial partial-thickness burn injuries to the lower extremities. The client is ordered IV morphine for pain. The nurse understands narcotics are given via IV during the initial management of pain because a. The client can experience nausea and emesis when given oral medications. b. Pain resulting from a burn injury requires relief by the fastest route available. c. Bleeding may occur at injection sites when the intramuscular route is used. d. Tissue edema may interfere with drug absorption via other routes.
d. Tissue edema may interfere with drug absorption via other routes.
A 25-year-old female patient has sustained burns to the anterior right arm, anterior trunk, posterior of the left leg, and anterior head, neck, and perineum. Using the Rule of 9's, what is the TBSA percentage of the burn?
37%
Ben comes to the ER with anterior second degree burns to the right arm, the entire chest, and both legs anterior and posterior. Using the Rule of 9's, calculate his TBSA.
58.5%
A patient with suspected septic shock has a rapid heart rate, low blood pressure (stable), and altered mental status. After ensuring airway, breathing and a stable BP what is the next best step in the management of this patient? A. Administer broad-spectrum antibiotics B. Immediate intubation C. Start vasopressor therapy D. Obtain blood cultures
A. Administer broad-spectrum antibiotics
A patient has a lactate levels of 5mmol, BP: 70/55, a decreased LOC that is not resolved with interventions. What stage of sepsis would they be in currently? A.SIRS B.Sepsis C.Severe Sepsis D.Septic Shock
D.Septic Shock
Patient comes into the ER with cardiac tamponade. What type of shock are they most likely experiencing? A.Hypovolemic B.Cardiogenic C.Analactic D.Neurogenic E.Obstructive
E.Obstructive
What is the best intervention to prevent compartment syndrome in circumferential burns?
Escharotomy
True or False? Treatment for MODS is continuing to monitor vital signs, and administering Naloxone every 12 hrs.
False
Name that burn Waxy, red and white to leathery gray skin that is dry and firm with absent hair. No blanching
Full thickness, 3rd degree burn
Name that burn Waxy, white to leathery gray to charred skin that is dry and firm with absent hair. No blanching Burn extends into the facia and/or muscle and bones. Painless because the nerve endings are destroyed.
Full thickness, 4th degree burn
Name that burn Wet, waxy, red to pale skin that does not blanch
Superficial deep partial thickness, 2nd degree burn
Name that burn Fluid-filled vesicles that are red/yellow, shiny, wet (if vesicles have ruptured). Severe pain caused by nerve injury. Mild to moderate edema.
Superficial deep thickness, 2nd degree
Calculate fluid resuscitation using parkland formula. Pt is 55kg with 60% TBSA.
Total fluid to be infused in 24hrs = 13,200mLFirst 8hrs = 6,600mLSecond 8hrs = 3,300mL per 8hrsThird 8hrs = 3,300mL per 8hrs
True or False? MODS is defined as severe organ dysfunction of at least two organ systems lasting at least 24 to 48 hours.
True
The nurse is monitoring for fluid and electrolyte changes in the emergent phase of burn injury for a patient. Which of the following will be an expected outcome? SATA a. Base-bicarbonate deficit b. Elevated hematocrit level c. Potassium deficit d. Sodium deficit e. Magnesium deficit
a. Base-bicarbonate deficit b. Elevated hematocrit level d. Sodium deficit
A patient is admitted to the medical floor with sepsis he has the following assessment findings: Bp 84/70, T: 101.9, RR:26, Lactate: 6mmol Creatinine: 3, GFR: 27. The patient received IV fluids for AKI. Renal dysfunction resolved after fluid initiate. What stage of sepsis is this patient in? a.SIRS b.SEPSIS c.Severe Sepsis d.Septic Shock
c.Severe Sepsis
Which zone consists of the area where the injury is most severe and deepest? a. Zone of stasis b. Zone of necrosis c. Zone of hyperemia d. Zone of coagulation
d. Zone of coagulation
_________ can fade over time, however, _______ develops altered contours. A.Discoloration, scar tissue B.Flaking skin, varicose veins C.Bone pain, increased sensation D.Nausea, coagulopathies
A.Discoloration, scar tissue
A patient presenting with distributive shock is hypotensive after anaphylaxis. Which initial medication is most appropriate? A.Epinephrine B.Dopamine C.Nitroglycerin D.Furosemide
A.Epinephrine
Which of the following requires surgical debridement? A.Full thickness B.Partial thickness C.Superficial thickness D.Epithelialization from margins
A.Full thickness
A 56-year-old male is admitted with signs of decreased tissue perfusion and hypotension after a severe gastrointestinal bleed. What type of shock is he most likely experiencing? A.Hypovolemic shock B.Cardiogenic shock C.Distributive shock D.Obstructive shock
A.Hypovolemic shock
The nurse is caring for a patient who is in the emergent phase following a burn injury. What are priority interventions the nurse should take? SATA A.Initiate fluid replacement therapy B.Administer IV pain medications C.Perform a neuro assessment D. Debride necrotic skin
A.Initiate fluid replacement therapy B.Administer IV pain medications D. Debride necrotic skin
When does the acute phase of burn management start? A.Mobilization of extracellular fluid and diuresis B.Mobilization of intracellular fluid and diuresis C.Mobilization of extracellular fluid and urinary retention D.Mobilization of intracellular fluid and urinary retention
A.Mobilization of extracellular fluid and diuresis
Inspection of the skin is an important part of nursing assessment. Interpretation of abnormalities is based on an understanding of structure and function. The nurse is aware that the epidermis, has many vital functions. What are some of these functions? A.Provides an effective barrier to water loss B.Contains the nerve receptors for pain perception C.Contains lipids that resist penetration by microbes D.Provides elasticity of the skin's foundation E.Produces keratin F.Secretes fibroblast cells that help repair the skin
A.Provides an effective barrier to water loss C.Contains lipids that resist penetration by microbes E.Produces keratin
A nurse suspected obstructive shock what could be the cause of the shock. SATA A.Tension pneumothorax B.COPD C.Pulmonary embolism D.Cardiac tamponade E.Allergic reaction F.Excessive vomiting and diarrhea
A.Tension pneumothorax C.Pulmonary embolism D.Cardiac tamponade
A patient is in hypovolemic shock what are indicators that the patient status has improved? A.Urine output of 30ml per hour. B.Systolic BP of 85 C.Heart Rate of 125 D.Respirations of 30
A.Urine output of 30ml per hour.
A patient in the burn unit receives skin tissue from a cadaver, what type of graft is this patient receiving? A.Xenograft B.Autograft C.Allograft D.Cultured epithelial autograft
C.Allograft
Patient with burns to their ears are at increased risk for __________ due to _________ and should avoid __________. A.Contractures, splinting, pillows B.Infection, trauma, blankets C.Infection, poor vascularization, pillows D.Decreased cardiac output, improper hand hygiene, therapeutic communication
C.Infection, poor vascularization, pillows
In a patient with cardiogenic shock, what clinical finding would differentiate it most clearly from hypovolemic shock? A.Hypotension B.Tachycardia C.Jugular venous distention (JVD) D.Decreased urine output
C.Jugular venous distention (JVD)
Patient has confirmed sepsis and has new onset of BP - 80/42, creatinine of 2.1, GFR of 40, and SpO2 of 88% on RA. does this patient meet MODS criteria and if so which organs are being affected. SATA A.CNS B.Gastrointestinal C.Renal D.Lung E.Cardiovascular
C.Renal D.Lung E.Cardiovascular
How many of the SIRS criteria are required to make a diagnosis of SIRS. A.Five B.None C.Two D.One
C.Two
The patient with a major burn develops massive systemic edema. What are they at risk for? a.Compartment syndrome b.Cardiogenic Shock c.Metabolic Alkalosis d.Deep puncture wound
a.Compartment syndrome
What prehospital care is necessary for chemical burns SATA? a.Copious flushing b.Remove loose clothing c.Remove adhere clothing d.Submerge body is cool water e. Transfer to a burn center
a.Copious flushing b.Remove loose clothing e. Transfer to a burn center
Name that burn Erythema, Blanches with pressure, pain and mild swelling. NO VESICLES or blisters (however may blister after 24 hours as well as peel).
Superficial partial, 1st degree
An upper airway injury from a burn affects the pulmonary system in what way? SATA a.High risk for pneumonia b.Bronchospasms c.Increase in ciliary clearance d.Loss of chest wall compliance e.Respiratory complications up to 4 hours post-injury
a.High risk for pneumonia b.Bronchospasms d.Loss of chest wall compliance
In the emergent/resuscitative phase of burn injury, it is crucial to anticipate and assess fluid and electrolyte alterations. Which of the following factor(s) are relevant in this context? SATA a.Reduced blood volume b.Metabolic acidosis c.Increased renal blood flow d.Metabolic alkalosis e.Respiratory acidosis f.Potassium enters the extracellular fluid
a.Reduced blood volume b.Metabolic acidosis f.Potassium enters the extracellular fluid
The nurse cares for a client with extensive burn injuries. Which parameter(s) would the nurse evaluate to determine if the client is receiving adequate fluid resuscitation? SATA a. Blood pressure b. Heart rate c. Urine output d. Oxygen saturation
a. Blood pressure b. Heart rate c. Urine output
A client with an acute myocardial infarction demonstrates signs of cardiogenic shock. Which medications will the nurse expect to be prescribed for this client? SATA a. Dopamine b. Dobutamine c. Nitroglycerin d. Diphenhydramine e. Vasopressin
a. Dopamine b. Dobutamine c. Nitroglycerin e. Vasopressin
Specific potential complications are common to specific types of burns. Which burns can impair ventilation? a. Face, neck and chest b. Perineal c. Hands, major joints d. Legs
a. Face, neck and chest
A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of their body. What would be the nurse's priority concern in the immediate care of this patient? a. Fluid status b. Risk of infection c. Body image d. Anxiety
a. Fluid status
What are the expected findings in the fluid remobilization phase (acute phase, diuresis) that the nurse should monitor for? SATA a. Hemodilution b. Increased urinary output c. Metabolic alkalosis d. Sodium deficit e. Hypoglycemia
a. Hemodilution b. Increased urinary output d. Sodium deficit
A client is brought to the emergency department with a burn injury. The nurse knows that the first systemic event after a major burn injury is what event? a. Hemodynamic instability b. Gastrointestinal hypermobility c. Respiratory arrest d. Hypokalemia e. Metabolic alkalosis
a. Hemodynamic instability
During the emergent/resuscitative phase of the burn injury, fluid and electrolyte changes are expected and need to be evaluated. Which of the following apply in this scenario? SATA a. Reduced blood volume b. Metabolic acidosis c. Potassium enters the extracellular fluid d. Increased renal blood flow e. Metabolic alkalosis f. Increased blood volume to the extremities
a. Reduced blood volume b. Metabolic acidosis c. Potassium enters the extracellular fluid
A nurse is providing care to all of the following clients. Which would be at increased risk for anaphylactic shock? SATA a. The client who is in the first 15 mins of receiving 1 U of PRBCs b. The 55 yo client with spina bifida c. The client who is scheduled for a repeat CT scan of the abdomen d. The client with an infection who is prescribed IV vancomycin e. The client who reports an allergy to peanuts that causes throat swelling.
a. The client who is in the first 15 mins of receiving 1 U of PRBCs b. The 55 yo client with spina bifida e. The client who reports an allergy to peanuts that causes throat swelling.
A client with a critical illness has a temperature of 38.5°C (101.3°F). Which parameters will the nurse use to determine if the client is developing severe sepsis? SATA a. UOP b. Bilirubin level c. PLT count d. BP e. Cardiac rhythm f. Respiratory rate
a. UOP b. Bilirubin level c. PLT count d. BP f. Respiratory rate
Question: The nurse cares for a 30-year-old client who suffered severe head and facial burn injuries. Which action, if completed by the client, indicates the client is adapting to altered body image? SATA a. Wears hats and wigs b. Covers face with a scarf c. Participates actively in daily activities d. Reports absence of sleep disturbance
a. Wears hats and wigs c. Participates actively in daily activities
Match the example of the type of burn. a. hot metal, tar, or grease b. touching wire equipment c. open flame explosion d. heat or flames
a. hot metal, tar, or grease b. touching wire equipment - conductive electrical c. open flame explosion d. heat or flames - contact/thermal
Which of the following would describe a superficial deep thickness second degree burn? SATA a. painful b. nonedematous c. fluid filled vessels that are red yellow and color d. nonblanchable
a. painful c. fluid filled vessels that are red yellow and color
An adult patient has burns to the entire left leg, minus the foot, the entire posterior left arm plus the hand. Calculate the TBSA, using the Lund-Browder chart. a.21.5% b.13.5% c.23.5% d.27%
a.21.5%
What initial diagnostics do you need for a burn patient? SATA a.Chest x-ray b.CMP c.CO d.ABGs e. BNP
a.Chest x-ray b.CMP c.CO d.ABGs
