Burns
The nurse anticipates supplementary feeding via a nasogastric tube in a patient for which reasons? (Select all that apply.) A. Hypermetabolic state B. Multiple open wounds C. Increased heat loss D. Increased caloric needs E. Burn greater than 20% TBSA
A) Hypermetabolic state B) Multiple open wounds D) Increased caloric needs E) Burn greater than 20% TBSA Rationale: Supplemental nutrition should be considered for any burn patient who has sustained a burn greater than 20% TBSA. In addition, burn patients have open wounds and are in a hypermetabolic state, resulting in increased caloric needs.
The nurse recognizes that burns to which body areas meet the criteria for referral to a burn center because of the increased risk of functional changes? (Select all that apply.) A. Chest B. Perineum C. Elbows D. Face E. Hands
B. Perineum C. Elbows D. Face E. Hands Rationale: According the American Burn Association, referral criteria to a burn center involves injuries to specific areas of the body including the face, hands, feet, genitalia, perineum and burns over major joints. Burns in these locations involve functional areas of the body and may require specialized and highly skilled intervention in order to restore optimal function.
A patient weighing 100 kg sustains a burn at 1400 covering approximately 50% TBSA. The patient is a young healthy male with no medical history. Using the Parkland formula, how much fluid should be infused by 1800? A. 20,000 ml lactated Ringer's B. 10,000 ml lactated Ringer's C. 5,000 ml lactated Ringer's D. 2,000 ml lactated Ringer's
C. 5,000 ml lactated Ringer's Rationale: The Parkland formula is 4 ml x 100 kg x 50% TBSA = 20,000 ml. Half of this amount (10,000ml) needs to be given in the first 8 hours therefore half that amount (5,000ml) needs to be given within the first 4 hours of resuscitation.
The nurse is caring for a child with a severe burn. The treatment for this child during the first 48 hours will be most likely be related to:
Hypovolemic shock
A nurse is working as part of a response team caring for children who have been involved in an elementary school fire. Which children would the nurse identify as needing a referral to a burn unit? Select all that apply. a) 9-year-old with asthma and burns to the face b) 6-year-old with burns involving the knees and hips c) 8-year-old with an inhalation injury d) 10-year-old with partial-thickness burns over 15% of the body e) 7-year-old with superficial burns over 5% of the body
a) 9-year-old with asthma and burns to the face b) 6-year-old with burns involving the knees and hips c) 8-year-old with an inhalation injury d) 10-year-old with partial-thickness burns over 15% of the body
In caring for a 3 ½-year-old child admitted after being severely burned, the nurse collects the following data. What finding would be most important for the nurse to report immediately? a) The child's respiratory rate is 32 breaths a minute. b) The child's pain level is a 7 on the pain scale. c) The child's hourly urinary output is 150 cc. d) The child's temperature is 101.2° F (38.4° C).
a) The child's respiratory rate is 32 breaths a minute.
The nurse is examining a child for indications of frostbite and notes blistering with erythema and edema. The nurse notes which degree of frostbite? a) Second degree frostbite b) Third degree frostbite c) First degree frostbite d) Fourth degree frostbite
a) second degree frostbite
The nurse is caring for a 2-month-old in a pediatric clinic. The mom states she is going on vacation in Florida in a month and she is concerned about sunburn. She asks if it is okay to use a sunscreen lotion made for children. What is the correct nursing response? a) "You should not take your infant to Florida." b) "Sunscreen is not recommended until 6 months of age. Use light clothing and a hat to completely cover the child when in the sun." c) "Put plenty of children's sunscreen on the infant at least 15 minutes before going outdoors, then reapply every three to four hours." d) "It is okay to use a children's sunscreen as long as you avoid the face."
b) "Sunscreen is not recommended until 6 months of age. Use light clothing and a hat to completely cover the child when in the sun."
The nurse is caring for a child with burns in a pediatric hospital. What would be an appropriate nursing diagnosis for this client? a) Knowledge deficit related to daily care procedures in the acute care setting b) Acute pain related to thermal injuries and procedures c) Risk for fluid volume overload related to thermal injuries d) Risk for aspiration related to effects of medication
b) Acute pain related to thermal injuries and procedures
The nurse is conducting a physical examination of a child with severe burns. Which internal physiologic manifestation should the nurse expect to occur first? a) Insulin resistance b) Decrease in cardiac output c) Hypermetabolic response with increased cardiac output d) Increased protein catabolism
b) Decrease in cardiac output
The nurse is caring for a child with a partial-thickness burn. What assessment findings would the nurse expect to observe? a) Edema with dry or waxy-looking skin b) Edema with wet blistering skin c) Peeling skin with eschar d) Reddened and leathery skin
b) Edema with wet blistering skin
What accurately depicts the hemodynamic changes that occur in the body within the first 24 to 48 hours after a burn? a) Hematocrit increases and WBC count decreases b) Hematocrit and WBC counts elevate c) Hematocrit and WBC counts decrease d) Hemoglobin and WBC counts decrease
b) Hematocrit and WBC counts elevate
The process of removing necrotic tissue in the treatment of burns is known as: a) Allograft b) Hydrotherapy c) Débridement d) Autograft
c) Débridement
A nurse is caring for a burn patient with second and third degree burns on 15% of the body. The patient is complaining of severe itching in and around the burn sites. Which of the following is the best nursing intervention to relieve this symptom? a) Diversional activities b) Turning the patient every two hours c) Medication d) Soaking in a colloidal bath
c) Medication
The nurse is caring for a 2-year-old boy with a burn. What finding would warrant referral to a burn unit? a) A superficial burn on his chest b) A superficial burn on his hand c) A first-degree burn on the upper arm d) A chemical burn
d) A chemical burn
A school-age child is brought to the office of the camp nurse with a small, superficial burn. Which action by the nurse would be the most appropriate action for the nurse to do first? a) Cover the area with a sterile bandage. b) Apply a topical anesthetic ointment. c) Administer acetaminophen. d) Apply cold compresses to the area.
d) Apply cold compresses to the area
The nurse is caring for a child admitted with partial thickness burns. What is most characteristic of this type of burn? a) Muscle damage occurs b) Skin is red and edematous c) Pain is minimal d) Blisters appear
d) Blisters appear
The nurse correlates which clinical manifestations to the possibility of an inhalation injury? (Select all that apply.) A. Facial burns B. Singed nasal hairs C. Soot in the sputum D. Hoarseness E. Eschar
A) Facial burns B) Singed nasal hairs C) Soot in sputum D) Hoarseness Rationale: Patients that have sustained an inhalation injury may have facial burns, singed nasal hairs, soot in their sputum, and hoarseness caused by edema and irritation. An abnormal EKG is not indicative of an inhalation injury.
The nurse correlates which zone of burn injury as the most susceptible to sustained injury because of insufficient fluid resuscitation? A. Zone of stasis B. Zone of conversion C. Zone of hyperemia D. Zone of coagulation
A. Zone of stasis Rationale: The zone of stasis immediately surrounds the zone of coagulation and is characterized by damaged cells and impaired circulation. It is this area of the burn that is most at risk for conversion if the patient does not receive adequate resuscitation. The zone of coagulation is the area that has the most contact with the heat source and is the location of the most severe damage. The outermost area is termed the zone of hyperemia and is generally an area of increased blood flow in an effort to bring key nutrients for tissue recovery.
A patient is admitted to the emergency room after sustaining an electrical burn with contact points to his right hand and left foot. The patient is being resuscitated with lactated Ringer's solution using the consensus formula. A urinary catheter was placed, and the nurse observes myoglobin in the urine along with a decrease in urine output. What is the most appropriate nursing action? A. Give the patient a normal saline fluid bolus. B. Notify the physician and anticipate increasing the intravenous fluid rate. C. Administer a diuretic. D. Continue monitoring the patient.
B) Notify the physician and anticipate increasing the intravenous fluid rate. Rationale: To prevent myoglobin from obstructing the renal tubules, the intravenous fluid rate needs to be increased.
The nurse recognizes which etiology as consistent with a thermal burn? A. Direct current B. Scalding C. Exposure to organic compounds D. Ionizing radiation
B. Scalding Rationale: Thermal burns can be the result of a flash, scald, or contact with hot objects or flames. Direct current is a one directional constant flow of electricity. Radiation burns are associated with the industrial use of ionizing radiation, nuclear accidents, and therapeutic radiation treatment.
Which intervention is the most beneficial for a burn client undergoing a skin graft? a) Provide an egg-crate mattress or gel mattress for the client to lie upon. b) Provide around-the-clock pain medication as soon as pain is reported. c) Provide diversion activities for the client. d) Provide pain medication on a PRN schedule as soon as pain is reported.
b) Provide around-the-clock pain medication as soon as pain is reported.
Which intervention is the most effective in treating burn wound infections? a) Systemic intravenous antibiotics b) Topical antibiotics applied to the wound site c) Proper hand washing d) Systemic oral antibiotics
b) Topical antibiotics applied to the wound site
The nurse is caring for a 7-year-old with burns. Which finding would be highly suggestive of a child abuse-induced burn? a) Splash patterns b) Spattering pattern c) Stocking-glove pattern on hands or feet d) Nonuniform pattern
c) Stocking-glove pattern on hands or feet
The nurse is caring for a child who has received significant partial-thickness burns to the lower body. What is the priority assessment in the first 24h after injury? 1. fluid balance 2. wound infection 3. respiratory arrest 4. separation anxiety
1. fluid balance
The nurse anticipates which burn patients will require higher fluid volumes during resuscitation? (Select all that apply.) A. A 45-year-old female who sustained an inhalation injury B. A 65-year-old male with an extensive alcohol history C. A 22-year-old male who sustained an electrical D. A 32-year-old healthy female with a thermal burn
A. A 45-year-old female who sustained an inhalation injury B. A 65-year-old male with an extensive alcohol history C. A 22-year-old male who sustained an electrical Rationale: All patients selected have comorbidities which predispose them to typically require higher volumes of fluid during the resuscitation period.
A patient is admitted to the emergency room after sustaining a flash burn to his face. He presents with facial burns and singed nasal hair but is reporting no difficulty breathing. The nurse places the patient on 100% oxygen via face mask. Upon reassessment, the nurse notes that his voice has changed and the patient is reporting difficulty swallowing. What is the most appropriate nursing action? A. Notify the physician and anticipate endotracheal intubation. B. Obtain a chest radiograph. C. Administer a bronchodilator. D. Lower the rate of the patient's intravenous fluids.
A. Notify the physician and anticipate endotracheal intubation. Rationale: Patients who have sustained an inhalation injury may have difficulty swallowing and report hoarseness and/or a change in voice.
Three burn patients have been admitted to the emergency room. In order of most importance, rank the patients according to who would be seen first, second, and third by the nurse. A. A 5-year-old child who is crying and has sustained a scald burn to the palmer surface of his right hand B. A 45-year-old male who was in a house fire complaining of hoarseness C. A 30-year-old female with bilateral circumferential full thickness burns to her lower extremities
B, C, A Rationale: Patient B is at highest risk for respiratory compromise due to a possible inhalation injury and should be seen first. Patient C should be seen second due to the fact that the burns on the lower extremities are circumferential and circulation could be compromised. Although Patient A is a pediatric patient, he/she has no respiratory and/or circulatory compromise and can be seen third.
Which intervention is the priority for the patient during the emergent phase of burn management? A. Application of silver sulfadiazine cream B. Use of clean, dry sheets and warm blankets C. Initiation of wet normal saline dressings D. Maintaining the injured area open to air
B. Use of clean, dry sheets and warm blankets Rationale: The burn wound is not the first priority during the emergent resuscitative phase as more life-threatening issues often take precedence. The burn wound is covered with clean, dry blankets to prevent hypothermia, but the initiation of wound care may be delayed for several hours until the patient is stabilized.
The nurse correlates which clinical manifestation to superficial partial-thickness burns? A. Eschar B. Dry, leathery appearance C. Blisters D. Waxy appearance
C. Blisters Rationale: Superficial partial thickness burns often have wet, weeping blisters and are pink in color. Deep partial thickness burns appear waxy and do not have the characteristic weeping blisters that are seen in superficial partial thickness injuries. Full thickness burns generally have no blister formation, and are always very dry and feel like leather to the touch.
Using the Parkland formula, the nurse determines that a patient requires a total of 12 L of fluid in the first 24 hours post injury. How much of the total volume needs to be given within the first 8 hours? A. 4,000 mL lactated Ringer's B. 6,000 mL lactated Ringer's C. 8,000 mL lactated Ringer's D. 10,000 mL lactated Ringer's
B. 6,000 mL lactated Ringer's Rationale: According to the Parkland Formula, half of the total calculated volume is given within the first 8 hours.
The nurse recognizes which diagnostic test as most sensitive in a patient with a suspected electrical burn injury? A. Arterial blood gas B. CK-MB levels C. Echocardiogram D. Serum carboxyhemoglobin
B. CK-MB levels Rationale: For electrical injuries, it is important to obtain a baseline EKG, troponin and CK-MB levels. A serum carboxyhemoglobin level is obtained on all patients with suspected inhalation injuries. Arterial blood gases are important to monitor overall respiratory status, but are not selective to electrical injuries. Likewise, an echocardiogram is indicated for assessment of cardiac function that would not be immediate in the patient after a burn injury.
When hemodynamic status is monitored in a patient with a burn injury, what amount of urine output indicates adequate fluid resuscitation? A. 0.5 mL/kg/hr B. 1 mL/kg/hr C. 2 mL/kg/hr D. 3 mL/kg/hr
A. 0.5 mL/kg/hr Rationale: Adequate urine output of 0.5 ml/kg/hr is crucial in a burn patient to maintain tissue perfusion and organ function.
A 25-year-old male presents to the emergency room with a chemical burn to his hand. What is the nurse's first intervention? A. Delay treatment until the chemical is able to be identified. B. Elevate the extremity to promote circulation. C. Protect yourself, remove the patient's clothing, and begin irrigation with copious amounts of water. D. Contact The Poison Control Center to determine the most appropriate neutralizing agent.
C. Protect yourself, remove the patient's clothing, and begin irrigation with copious amounts of water. Rationale: Personal safety is always first priority, followed by irrigation with water.
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
b. Full-thickness skin destruction 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.
