NSG252 - Lewis Burns EAQ
The nurse is providing education to a patient with an arm burn who is in the rehabilitation phase of recovery. Which statement by the patient indicates a need for further instruction? "If the area itches, I can apply a water-based moisturizer." "After a month, I will be able to go to the beach to get a tan. "I will need to wear the pressure garment for 24 hours a day. "I will continue the range-of-motion exercises on a regular schedule."
"After a month, I will be able to go to the beach to get a tan. Rationale Burn patients must protect healed burn areas from direct sunlight for about three months to prevent hyperpigmentation and sunburn injury. They should always wear sunscreen when they are outside. Water-based moisturizers are appropriate for itching. Pressure garments and masks should never be worn over unhealed wounds and, once a wearing schedule has been established, are removed only for short periods while bathing. Pressure garments are worn up to 24 hours a day for as long as 12 to 18 months. The range-of-motion exercises are important to prevent contractures that may develop as new tissue shortens.
The nurse is teaching strategies to reduce burn injuries to a group of new parents. Which parent comment indicates a need for further teaching? "We will have fire exit drills once a month at home." "I will not use gasoline in the fireplace when starting a fire. "I will make sure the hot water temperature is set at 140° F (60° C)." "We will install hard-wired smoke detectors on each level of our home.
"I will make sure the hot water temperature is set at 140° F (60° C)." Rationale Hot water heaters set at 140° F (60° C) or higher are a burn hazard in the home; the temperature should be set at less than 120° F (40° C). A risk-reduction strategy for household fires is to encourage regular home fire exit drills. Gasoline or other flammable liquids should never be used to start a fire. Installation of smoke and carbon monoxide detectors can prevent inhalation injuries. Hard-wired smoke detectors do not require battery replacement; battery-operated smoke detectors may be used.
A patient with partial-thickness burns is being treated with zolpidem, and the family inquires why the patient is receiving the medication. Which responses by the nurse are appropriate? Select all that apply. "It is used to help promote sleep. "It is used to reduce anxiety." "It is used to promote wound healing." "It is used to prevent thromboembolism. "It is used to provide short-term amnesic effects."
"It is used to help promote sleep. "It is used to reduce anxiety." "It is used to provide short-term amnesic effects." Rationale Zolpidem is a sedative-hypnotic medicine and is given to patients suffering from burns. Zolpidem promotes sleep, reduces anxiety, and provides short-term amnesic effects. Nutritional support is used to promote wound healing. Anticoagulants are used to prevent thromboembolism.
A burn patient's caregiver asks the nurse why an enzymatic deriding agent is being applied to the wounds. Which response by the nurse is appropriate? "The enzymatic debriding agent helps decrease blood loss. "The enzymatic debriding agent helps remove the old microbial agent." "The enzymatic deriding agent helps protect the re-epithelializing keratinocytes." "The enzymatic deriding agent helps remove dead tissue from the healthy wound bed."
"The enzymatic deriding agent helps remove dead tissue from the healthy wound bed." Rationale Enzymatic deriding agents are made of natural products like collagen. Enzymatic deriding agents speed up the removal of dead tissue from the healthy wound bed. Skin grafting, a part of wound care, promotes massive blood loss in patients. To prevent this, topical application of epinephrine is advised. Washing the patient's wound with normal saline-moistened gauze removes the old antimicrobial agent. Paraffin gauze dressing protects the re-epithelializing keratinocytes from damage. This dressing resurfaces and closes the open wound bed.
As per the Parkland (Baxter) formula, the estimated total fluid requirement in the first 24 hours for a severely burned patient who weighs 80 kg and has burns on more than 40% of the total body surface area (TBSA) would be ___________________- mL Record your answer using a whole number and no punctuation.
12800 Rationale According to the Parkland (Baxter) formula: 4 mL of lactated Ringer's solution should be administered per kilogram (kg) of body weight per percentage of TBSA burned in the first 24 hours after the burn. For an 80-kg patient with a 40% TBSA burn, 4 mL × 80 kg × 40 TBSA burned = 12,800 mL in 24 hours
The nurse recognizes which fluid as recommended for the first 24 hours after a burn? 1 to 2 mL lactated Ringer's/kg/percent total body surface area (%TBSA) burned 2 to 4 mL lactated Ringer's/kg/%TBSA burned 6 to 8 mL lactated Ringer's/kg/%TBSA burned 8 to 10 mL lactated Ringer's/kg/%TBSA burned
2 to 4 mL lactated Ringer's/kg/%TBSA burned Rationale Fluid resuscitation is an important intervention in burn management. It helps to replenish the fluid loss caused by burns and maintain the fluid and electrolyte balance. The fluid recommendation for the first 24 hours is 2 to 4 mL lactated Ringer's/kg/%TSA burned. A fluid volume of 1 to 2 mL lactated Ringer's/kg /%BSA burned would be inadequate to meet the patient's requirement. Volumes of 6 to 8 mL lactated Ringer's/kg/%TBSA burned and 8 to 10 mL lactated Ringer's/kg/%TBSA burned may cause fluid overload.
Which patients are appropriate for the nurse to refer to the burn center? Select all that apply. A patient with burns of the feet A patient with an inhalation injury An elderly patient with third-degree burns A patient with burns involving minor joints A patient with partial-thickness burns involving 8% of total body surface area
A patient with burns of the feet A patient with an inhalation injury An elderly patient with third-degree burns Rationale A burn care unit provides advanced care to burn patients to prevent complications and keep the condition from worsening. An inhalation injury increases the risk of airway obstruction and requires a referral to the burn unit. Burns on both feet are associated with complications like contractures, and the patient needs to be referred to the burn care unit. Third-degree burns in any age-group require referral. Burns involving minor joints do not require referral to burn centers; however, burns of major joints require referral. Partial-thickness burns require referral if they involve more than 10% of the body surface area.
A burn patient has not received any active tetanus immunization within the previous 12 years. Which is the primary nursing measure to help prevent the development of tetanus in the patient? Administer tetanus toxoid. Provide musculoskeletal relaxants Provide 100% oxygen to the patient. Administer tetanus immunoglobulin.
Administer tetanus immunoglobulin. Rationale Because the patient has not received any active immunization in the past 12 years, tetanus immunoglobulin administration is the primary measure. It would help in preventing the development of tetanus. Tetanus toxoid administration would have been the primary measure if the patient had received active immunization within the past 10 years. Providing 100% oxygen does not ensure aerobic conditions at the burn area. Musculoskeletal relaxants will be helpful only after the patient develops tetanus.
Which action is most appropriate for the nurse to take during the early course of the care of a patient who has sustained burns covering 35% of the body surface area and weighs 100 kg? Administering 3500 mL of colloid IV fluids over the 8 hours after injury Administering 140 mL/hr of colloid IV fluids for the 24 hours after injury Administering 7000 mL of crystalloid IV fluids over the 8 hours after injury Administering 14,000 mL of crystalloid IV fluids over the 12 hours after injury
Administering 7000 mL of crystalloid IV fluids over the 8 hours after injury Rationale Crystalloid solutions, such as Ringer's lactate, are indicated for use in the initial IV fluid therapy for a burn patient. IV fluids for the first 24 hours may be calculated with the use of the Parkland formula based on body surface area (BSA), 4 mL/kg × BSA; therefore (4 mL × 100 kg) × 35 = 14,000 mL. The Parkland formula calls for half of the total fluids to be given over the first 8 hours, with the remaining given over the next 16 hours. Therefore the IV fluid prescription would be 7000 mL over 8 hours and 7000 mL over the next 16 hours. Administering 3500 mL of colloid IV fluids over the first 8 hours or 140 mL/hr of colloid IV fluids for 24 hours is incorrect because the volumes are incorrect and because colloid fluids are not used during the fluid resuscitation period for burns (first 24 hours).
The nurse assesses a patient who was brought in with burn injuries on the face, upper chest, and hands. The patient exhibits singed nasal hair and has darkened oral and nasal membranes. Which action would be the most appropriate for the nurse to take next? Insert a Foley catheter and monitor output. Obtain vital signs and a stat arterial blood gas (ABG). Obtain a sputum specimen and send it to the lab stat. Anticipate the need for endotracheal intubation and notify the health care provider.
Anticipate the need for endotracheal intubation and notify the health care provider. Rationale Inhalation injury results from exposure of the respiratory tract to intense heat or flames with inhalation of noxious chemicals, smoke, or carbon monoxide. The nurse should anticipate the need for endotracheal intubation and mechanical ventilation because this patient is demonstrating signs of severe respiratory distress. The nurse should also obtain vital signs and ABGs and insert a Foley, but these interventions are not a priority at this time. A sputum sample is not necessary at this time.
A patient recovering from third-degree burns over 30% of the body is ready for discharge and asks the nurse, "What's going to happen to me? Will I ever look normal again?" The nurse recognizes that this patient is exhibiting which emotional response to the burn injury? Fear Guilt Anxiety Depression
Anxiety Rationale Recovery from a 30% total body surface area (BSA) burn injury takes time and is exhausting, both physically and emotionally for the patient. The health care team may think that a patient is ready for discharge, but the patient may not have any idea that discharge is being contemplated in the near future. Patients are often very fearful about how they will manage at home. Although fear, anger, guilt, and depression are all common emotions experienced by a burn patient, this patient's statements reflect feelings of anxiety.
A patient's partial-thickness burn injuries were derided and covered with a silver-impregnated dressing a week ago. Today the nurse notes the wounds have been fully debrided. Which would be the nurse's priority intervention for wound care at this time? Reapply a new dressing without disturbing the wound bed. Apply fine-meshed petroleum gauze to the debrided areas. Wash the wound aggressively with sterile saline three times a day. Apply cool compresses for pain relief in between dressing changes.
Apply fine-meshed petroleum gauze to the debrided areas. Rationale When the partial-thickness burn wounds have been fully debrided, a protective, coarse- or fine-meshed, greasy-based (paraffin or petroleum) gauze dressing is applied to protect the re-epithelializing keratinocytes as they resurface and close the open wound bed. The nurse would not wash the wound aggressively with saline three times daily, apply cool compresses, or apply a new dressing at this time.
Which actions would the nurse perform when caring for a patient who experienced an inhalation injury and is not intubated? Select all that apply. Assist in performing a fiberoptic bronchoscopy. Reposition the patient every one to two hours. Avoid administering 100% humidified oxygen. Do not place the patient in a high-Fowler's position. Encourage deep breathing and coughing every hour.
Assist in performing a fiberoptic bronchoscopy. Reposition the patient every one to two hours. Encourage deep breathing and coughing every hour. Rationale Within 6 to 12 hours after the burn injury in which smoke inhalation is suspected, a fiberoptic bronchoscopy should be performed to assess the lower airway. Reposition the patient every one to two hours, and provide suctioning and chest physiotherapy, as prescribed, to clear the airway. Encourage deep breathing and coughing every hour to clear the air passages and provide relief to the patient. When intubation is not performed, the treatment of inhalation injury includes administration of 100% humidified O 2 as needed. Place the patient in a high-Fowler's position, unless contraindicated, as in spinal injury, and encourage deep breathing and coughing every hour.
Which precautions would the nurse take to protect a patient with burns on the face and the ears from further damage? Select all that apply. Avoid using pillows. Keep ears free from pressure. Apply a heavy gauze dressing for fast healing. Wrap ears with sterile gauze after applying ointment. Elevate the patient's head by placing a rolled towel under the shoulders.
Avoid using pillows. Keep ears free from pressure. Elevate the patient's head by placing a rolled towel under the shoulders. Rationale The ears should be kept free from pressure because of their poor vascularization and tendency to become infected. Avoid using pillows because the pressure on the ear cartilage may cause chondritis, and the ear may adhere to the pillowcase, causing pain and bleeding. The patient's head is elevated by placing a rolled towel under the shoulders to reduce pressure over the ears, which helps to prevent pressure necrosis. A heavy gauze dressing should not be applied because it can put pressure on the ears and damage them. The ears are not wrapped with sterile gauze after applying ointment in order to avoid pressure over the ears.
Which initial interventions would the nurse perform as a part of emergency burn management for a patient who has sustained full-thickness burns covering more than 20% of the total body surface area? Select all that apply. Begin fluid replacement. Avoid supplemental oxygen. Cover burned areas with dry dressings. Lower the burned limbs below the heart level Establish IV access with two large-bore catheters.
Begin fluid replacement. Cover burned areas with dry dressings. Establish IV access with two large-bore catheters. Rationale Begin fluid replacement to compensate for fluid loss. Cover the burned areas with dry dressings to begin the healing process and thus prevent contamination. IV access should be established with two large-bore catheters to enable large amounts of fluid replacement. Supplemental oxygen is required to maintain adequate perfusion. The injured limb should be kept elevated above the heart level to prevent and decrease swelling.
A patient is suspected to have a smoke inhalation burn and carboxyhemoglobinemia. In which order would the nurse perform the treatment interventions? Check the patient's pulse. Check for a patent airway and soot around the nares and tongue. Elevate any burned limbs above the heart to decrease pain and swelling Check for the adequacy of ventilation.
Check for a patent airway and soot around the nares and tongue. Check for the adequacy of ventilation. Check the patient's pulse. Elevate any burned limbs above the heart to decrease pain and swelling. Rationale The most important intervention is to check that the airway is patent. Then evaluate the adequacy of appropriate ventilation, followed by a check of the patient's pulse. Finally, elevate any burned limbs above the heart to decrease pain and swelling.
A patient has sustained thermal injuries amounting to approximately 30% of the total body surface area (BSA). Which action would the nurse take first? Cover the burned body area with ice. Immerse the burned body area in cool water. Check for a patent airway, breathing, and circulation. Cover the burned area with a clean, cool, tap water-dampened towel.
Check for a patent airway, breathing, and circulation. Rationale The first step in the management of a person who has sustained thermal injuries on 10% or more of his or her body surface is to assess the airway, breathing, and circulation. If the injury is less than 10% of TSA, then it would be appropriate to cover the burned area with a clean, cool, damp towel, but only after the airway, breathing, and circulation have been checked. It is not appropriate to cover the patient's afflicted area with ice because this can cause hypothermia and vasoconstriction, which would further reduce the blood flow to the injury site. Immersing the patient or the patient's afflicted area in cool water may cause extensive heat loss.
Which nursing interventions are appropriate for providing enteral feeding to a patient who is intubated and has burns of more than 5% of the total body surface area (TSA)? Select all that apply. Check gastric residuals frequently. Assess bowel sounds every eight hours. Determine whether the nasogastric tube is in place. Begin the feedings slowly at the rate of 10 to 20 mL/hr. Increase the feeding to the goal rate within 24 to 48 hours.
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. Rationale A patient who is intubated and has suffered burns to more than 5% of the TBSA may need gastric feedings to meet adequate nutritional requirements. Early enteral feeding helps to preserve gastrointestinal function, increase intestinal blood flow, and promote optimal conditions for wound healing. The nurse should check the placement of the nasogastric tube and assess bowel sounds every eight hours. The enteral feedings should be started at 20 to 40 mL/hr and slowly increased to the goal rate within 24 to 48 hours. Gastric residuals should be checked to rule out delayed gastric emptying.
A patient has thermal burns on the face, including the cheeks and the area around the eyes. Which action would the nurse take? Turn eyelashes inward toward the eyeball. Wrap sterile gauze around the face. Cover the face with ointment and gauze. Apply ointment only without the use of gauze.
Cover the face with ointment and gauze. Rationale The face is highly vascular and may become edematous after a thermal burn. It should be covered with ointment and gauze to prevent vascularization and swelling. The nurse should ensure that the eyelashes are not turned inward. Wrapping gauze around the face will create pressure on delicate facial structures. The gauze is required to cover the face after the application of ointment to prevent infection.
Which treatment would the nurse recognize as appropriate and within the scope of nursing practice when caring for a patient with partial-thickness second-degree burns to the chest, abdomen, and both anterior thighs? Application of autografts and daily sterile dressing changes Twice-weekly wound cleaning and sterile dressing changes Daily wound cleaning with debridement and sterile dressing changes Daily wound cleaning with hydrotherapy and clean dressing changes
Daily wound cleaning with debridement and sterile dressing changes Rationale Daily wound cleansing with debridement and sterile dressing changes is appropriate care for a major burn wound. As a means of promoting healing and preventing infection, wound care and dressing changes are performed once or twice a day with a sterile procedure. The other answer options are not
A nurse is instructing a patient about the immediate steps that need to be taken in the case of electrical burns. Which precautions would the nurse instruct as necessary to perform? Select all that apply. Do not cover the burned part with ice. Do not remove any burned clothing from the body. Do not immerse the burned part in cool water. Cool large burns for not more than 10 minutes. Apply ice to the burned part as early as possible.
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. Rationale The burned body part of a person suffering from an electrical injury should not be covered with ice because it can cause hypothermia and vasoconstriction and can significantly reduce the blood flow to the affected area. Do not immerse the burned part in cold water because it may cause extensive heat loss. Cooling burns for more than 10 minutes can cause hypothermia. Applying ice to the burned part can cause hypothermia. Burned clothes can be removed gently to avoid further tissue damage; however, clothes that are adhered to the body should not be removed.
Which interventions would the nurse expect to see included in the plan of care for a patient with partial- and full-thickness burns on the lower extremities? Select all that apply Escharotomy care Administration of diuretics Daily cleansing and debridement Application of topical antimicrobial agent IV and oral pain medications
Escharotomy care Daily cleansing and debridement Application of topical antimicrobial agent IV and oral pain medications Rationale Pain control is essential in the care of a patient with a burn injury. Daily cleansing and debridement, as well as the application of an antimicrobial ointment, are expected interventions used to minimize infection and enhance wound healing. An escharotomy (a scalpel incision through full-thickness eschar) frequently is required to restore circulation to compromised extremities. With full-thickness burns, myoglobin and hemoglobin released into the bloodstream can occlude renal tubules. Adequate fluid replacement is used to prevent this occlusion.
Which actions would the nurse perform when caring for a patient who received burns from hydrochloric acid on the hands and face? Select all that apply. Apply ice to the burned area. Never wash the burn with water. Flush affected area with lots of water. Remove all chemical particles on the skin. Remove all clothing containing the chemical.
Flush affected area with lots of water. Remove all chemical particles on the skin. Remove all clothing containing the chemical. Rationale Remove all chemical particles on the skin to remove the burn-causing agent from the patient's body. Remove all clothing containing the chemical because the burning process continues while the chemical is in contact with the skin. Flush affected areas with copious amounts of water to irrigate the skin from 20 minutes to two hours after chemical exposure to clear off the chemical on or around the affected area. Applying ice to the burned area does not help to wash away the chemical. Washing the burned area with water helps to clean off the chemical.
Which cardiac parameters would the nurse assess to determine the adequacy of fluid resuscitation in a patient who has sustained burns? Select all that apply. Heart rate less than 120 beats/minute Manual systolic BP greater than 90 mm Hg Arterial line systolic BP greater than 90 mm Hg Manual mean arterial pressure greater than 65 mm Hg Arterial line mean arterial pressure greater than 65 mm Hg
Heart rate less than 120 beats/minute Arterial line systolic BP greater than 90 mm Hg Arterial line mean arterial pressure greater than 65 mm Hg Rationale The cardiac parameters that help to assess the adequacy of fluid resuscitation are heart rate less than 120 beats/minute, arterial line systolic BP greater than 90 mm Hg, and arterial line mean arterial pressure greater than 65 mm Hg. Manual BP and manual mean arterial BP are invalid in burns because of edema and vasoconstriction.
The nurse is caring for a patient with partial- and full-thickness burns to 65% of the body. When planning nutritional interventions for this patient, which dietary choices would the nurse implement? Full liquids only Whatever the patient requests Low-sodium foods High-protein foods
High-protein foods Rationale A hypermetabolic state occurs proportional to the size of the burn area. Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. Caloric needs are often in the 5000-kcal range. Failure to supply adequate calories and protein leads to malnutrition and delayed healing.
Which patient signs and symptoms noted during triage would indicate to the nurse an upper airway injury? Select all that apply. Dyspnea Hoarseness Difficulty swallowing Copious secretions Carbonaceous sputum
Hoarseness Difficulty swallowing Copious secretions Rationale An inhalation injury in the upper airway involves the mouth, oropharynx, and/or larynx. It may cause hoarseness in the voice because of the effect on the larynx. There may be difficulty in swallowing because of the involvement of the mouth and oropharynx. There may be copious secretions in response to the injury to the airway. The injury to the lower airway involves the trachea, bronchioles, and alveoli and may cause carbonaceous sputum and dyspnea.
The nurse is teaching a community group about immediate actions to be taken in the case of burns to more than 10% of body surface area. Which reason would 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 stop further tissue damage. Ice can reduce blood flow to the burned area. Ice can increase the blood flow to the burned area.
Ice can cause hypothermia. Ice can cause vasoconstriction. Ice can reduce blood flow to the burned area. Rationale Ice can cause hypothermia, resulting in excessive cooling of the burned part and reduction of blood flow to that area. Ice can also cause vasoconstriction, thus causing the blood vessels supplying the burned area to narrow and supply less blood and oxygen. Applying ice does not prevent further tissue damage; instead, it decreases the blood supply, causing delayed wound healing. Ice does not increase the blood flow to the burned area; rather, it decreases the blood flow as a result of vasoconstriction.
Which advice would the nurse give to the family of an elderly patient to help prevent accidental burns? Cook for the patient. Stop the patient from smoking. Install tap water anti-scald devices. Be sure the patient uses an open space heater.
Install tap water anti-scald devices. Rationale Installing tap water anti-scald devices will help prevent accidental scald burns that more easily occur in older people because their skin becomes drier and the dermis thinner. Cooking for the patient may be needed at times of illness or in the future, but there is no indication that the patient needs this assistance. Stopping the patient from smoking may be helpful to prevent burns but may not be possible. Using an open space heater would increase the patient's risk of being burned and would not be encouraged.
A patient with burns needs permanent skin grafting. Which types of grafts would the nurse expect to be considered? Select all that apply. Integra AlloDerm Autograft Homograft Heterograft
Integra AlloDerm Autograft Rationale Integra is obtained from bovine collagen and glycosaminoglycan bonded to silicone and gives permanent coverage. AlloDerm is obtained from a cellular dermal matrix derived from donated human skin and can be used for permanent grafting. Autograft is from the patient's own skin and can be used for permanent grafting. Homograft is obtained from cadaveric skin and can be used as a temporary graft from three days to two weeks. Heterograft is obtained from porcine skin and can be used as a temporary graft from three days to two weeks.
When caring for a patient with an electrical burn injury, which prescription from the health care provider would the nurse question? Urine for myoglobin Lactated Ringer's at 25 mL/hr Mannitol 75 gm IV Sodium bicarbonate 24 mEq every 4 four hours
Lactated Ringer's at 25 mL/hr Rationale Electrical injury puts the patient at risk for myoglobinuria, which can lead to acute tubular necrosis (ATN).vTreatment consists of infusing lactated Ringer's at 2 to 4 mL/kg/% total body surface area (BSA), a rate sufficient to maintain urinary output at 75 to 100 mL/hr. An infusion rate of 25 mL/hr is not sufficient to maintain adequate urine output in the prevention and treatment of AT. Mannitol also can be used to maintain urine output. The urine would also be monitored for the presence of myoglobin. Sodium bicarbonate may be given to alkalinize the urine.
Which types of food and drinks would the nurse provide to the patient who is recovering from a full-thickness burn and is in a hypermetabolic state? Select all that apply. Tea Milkshakes Protein powder Low-protein food High-caloric food
Milkshakes Protein powder High-caloric food Rationale A patient with burns needs a high-calorie diet to compensate for the energy loss and increased protein intake to avoid malnutrition and delayed healing. Milkshakes have a lot of calories. Protein powder provides high protein. High-caloric food contains calories in large quantities and will help in the patient's recovery. Tea does not provide adequate quantities of calories and proteins. Low-protein food is not advised for a patient with burns because the demand for protein is high to promote healing and a faster recovery.
When teaching patients and caregivers about the strategies to reduce burn injuries, which essential instructions would the nurse include? Select all that apply. Perform outdoor activities during lightning storms. Never leave burning candles unattended or near windows or curtains. Ensure an electrical power source is shut off before beginning repairs. Check the temperature of bathwater with the back of the hand or a bath thermometer. Store chemicals in the lowest shelves to avoid mixing them up with other household cleaners.
Never leave burning candles unattended or near windows or curtains. Ensure an electrical power source is shut off before beginning repairs. Check the temperature of bathwater with the back of the hand or a bath thermometer. Rationale Ensure that the electrical power source is shut off before beginning any repairs to avoid electrical burn injury. Never leave candles unattended or near open windows or curtains to avoid fire. Check the temperature of the bathwater using the back of the hand or a bath thermometer to avoid scalding burns, which commonly occur as a result of hot bathing water. Chemicals should be stored safely, preferably out of reach of children, in containers with clearly written labels. Performing outdoor activities during lightning storms increases the risk of electrical injury from the ongoing lightning.
A nurse is caring for a patient with second- and third-degree burns to 50% of the body. The nurse prepares fluid resuscitation based on knowledge of the Parkland (Baxter) formula that includes which recommendation? The total 24-hour fluid requirement should be administered in the first eight hours. One half of the total 24-hour fluid requirement should be administered in the first eight hours. One third of the total 24-hour fluid requirement should be administered in the first four hours. One half of the total 24-hour fluid requirement should be administered in the first four hours.
One half of the total 24-hour fluid requirement should be administered in the first eight hours. Rationale Fluid resuscitation with the Parkland (Baxter) formula recommends that one half of the total fluid requirement should be administered in the first eight hours, one quarter of the total fluid requirement should be administered in the second eight hours, and one quarter of total fluid requirement should be administered in the third eight hours.
When planning for burn management, which patients would the nurse refer to a burn center? Select all that apply. Patients with hydrochloric acid burns Patients of all ages with first-degree burns Patients of all ages with third-degree burns Patients with 25% deep partial-thickness burns Patients with 5% superficial partial-thickness burns
Patients with hydrochloric acid burns Patients of all ages with third-degree burns Patients with 25% deep partial-thickness burns Rationale Patients suffering from hydrochloric acid burns, also known as chemical burns, should be referred to a burn center. Patients of all ages with third-degree burns are severe in condition and should be treated in a burn center. All patients with partial-thickness burns of more than 10% of body surface area should be referred to a burn center because they are severe types of burns and need specialized treatment, care, and isolation. Patients of all ages with first-degree burns can be managed in the hospital and assessed. Patients with 5% superficial partial-thickness burns need not necessarily be referred and can be managed in the hospital.
While planning physical therapy for a patient suffering from burns, which intervention would the nurse include in the plan of care? Select all that apply. Perform exercises before wound cleansing. Practice physical therapy only occasionally. Perform passive and active range of motion (ROM) on all joints. Provide pillows to sleep for patients with neck burns. Perform exercises during and after wound cleansing.
Perform passive and active range of motion (ROM) on all joints. Perform exercises during and after wound cleansing. Rationale Perform passive and active ROM on all joints to avoid contractures and prevent compromising the patient's cardiopulmonary status. It is not a good habit to practice physical therapy only occasionally. This is because continuous physical therapy throughout burn recovery is imperative if the patient needs to regain and maintain muscle strength and optimal joint function. A good time for exercise is during and after wound cleansing, when the skin is softer and bulky dressings are removed. Performing exercises before wound cleansing is not appropriate. Patients with neck burns should continue to sleep without pillows or with the head hanging slightly over the top of the mattress to encourage hyperextension and avoid contractures.
A patient is brought to the emergency department (ED) with a suspected inhalation injury and burns on the face, the neck, and the hands. Which actions would the nurse perform immediately? Select all that apply. Wait for laboratory reports. Observe for the next two hours. Provide 100% humidified oxygen. Observe for signs of respiratory distress. Check for evidence of inhalation of smoke.
Provide 100% humidified oxygen. Observe for signs of respiratory distress. Check for evidence of inhalation of smoke. Rationale Monitoring for signs of smoke or toxic chemical inhalation is an important step to evaluate burn victims. Also, assessing for signs of respiratory distress, including increased agitation, anxiety, restlessness, or a change in the rate or character of breathing, is important. Early treatment includes the provision of 100% humidified oxygen and anticipating endotracheal intubation. Observing the patient for the next two hours does not help because treatment must begin at the earliest possible moment. In general, the patient suffering from burns on the face and neck may have mechanical obstruction caused by massive swelling of the tissues and requires intubation within one to two hours after the injury
Which intervention would the nurse provide when caring for a patient with a burn injury during the acute phase? Provide teaching about the physical aspects of recovery. Discuss the possible need for home care nursing. Discuss the need for reconstructive surgery. Begin IV fluid replacement.
Provide teaching about the physical aspects of recovery. Rationale Nurses should provide ongoing support, counseling, and teaching to the patient and the caregiver regarding the physical and emotional aspects of care and recovery. Discussing the need for both home care following discharge and the need for reconstructive surgery occurs during the rehabilitation phase. Beginning fluid replacement occurs in the emergent phase.
When teaching the patient about the use of range of motion (ROM), which explanations would the nurse give to the patient? Select all that apply. The exercises are the only way to prevent contractures. ROM will show the patient that movement still is possible. Active and passive ROM maintain function of body parts. Movement facilitates mobilization of leaked exudates back into the vascular bed. Active and passive ROM can be done only while the dressings are being changed.
ROM will show the patient that movement still is possible. Active and passive ROM maintain function of body parts. Movement facilitates mobilization of leaked exudates back into the vascular bed. Rationale The explanations that should be used are that active and passive ROM maintain the function of body parts and reassure the patient that movement still is possible. Contractures are prevented with ROM as well as splints. Movement facilitates mobilization of fluid in the interstitial fluid back into the vascular bed. Although it is good to collaborate with physical therapy to perform ROM during dressing changes because the patient has already taken analgesics, ROM can and should be done throughout the day.
Which discharge instructions would the nurse include when teaching a patient with partial-thickness burns on the hands about rehabilitation at home? Select all that apply. Recommend exercises. Take low-dose antihistamines. Protect healed areas from direct sunlight. Apply water-based creams on healed areas. Inform the patient that wound care is not required at home.
Recommend exercises. Take low-dose antihistamines. Protect healed areas from direct sunlight. Apply water-based creams on healed areas. Rationale The nurse should advise the patient to take low-dose antihistamines because these can be used at bedtime if itching persists. The nurse should instruct the patient to protect healed areas from direct sunlight for 3 months to prevent hyperpigmentation and sunburn injury. Only water-based creams that penetrate into the dermis should be used routinely on healed areas to keep the skin supple and well moisturized. This helps to decrease itching and flaking. The nurse should also encourage the patient to perform physical and occupational therapy routines and recommended exercises. The patient may have small, unhealed wounds, and it is therefore important to carry out dressing changes and wound care at home.
The patient received a cultured epithelial autograft (CA) to the entire left leg. Which would the nurse include in the discharge teaching for this patient? Sit or lie in a position of comfort. Wear a pressure garment for eight hours each day. Refer the patient to a counselor for psychosocial support. Use the sun to increase the skin color on the healed areas.
Refer the patient to a counselor for psychosocial support. Rationale In the rehabilitation phase, the patient will work toward resuming a functional role in society, but there are frequently body image concerns and grieving for the loss of the way the body looked and functioned before the burn, so continued counseling helps the patient in this phase as well. Putting the leg in the position of comfort is more likely to lead to contractures than to help the patient. If a pressure garment is prescribed, it is used for 24 hours per day for as long as 12 to 18 months. Sunlight should be avoided to prevent injury, and sunscreen should always be worn when the patient is outside.
A patient with severe inhalation burns has been receiving treatment for 24 hours. When assessing the patient, which findings would indicate respiratory distress? Select all that apply. Restlessness Increased sleep Increased agitation Increased water intake Increased rate of breathing
Restlessness Increased agitation Increased rate of breathing Rationale Restlessness can result from respiratory distress because the patient experiences disturbances in breathing. Increased agitation could result from the patient's attempts to compensate for an increasing oxygen demand and can be a sign of respiratory distress. An increased respiratory rate is a compensatory mechanism for the increased oxygen demands. It is a sign of impending respiratory distress and needs immediate attention. Increased sleep does not result from respiratory distress because the patient becomes restless. Increased water intake is not specific to respiratory distress.
A patient with partial-thickness burns is now allowed oral feedings. Which nursing interventions would the nurse perform to maintain the patient's nutrition? Select all that apply. Suggest low-calorie foods. Suggest a high-protein diet. Suggest reduced fluid intake. Suggest a high-carbohydrate diet. Ask caregivers to get the patient's favorite food.
Suggest a high-protein diet. Suggest a high-carbohydrate diet. Ask caregivers to get the patient's favorite food. Rationale The patient may have a reduced appetite and may not like the food from the hospital. Therefore the caregivers can get the patient's favorite food. A swallowing assessment should be done by a speech pathologist before beginning with oral feeds. The patient should be provided with a high-protein diet to promote tissue healing and avoid malnutrition. A high-carbohydrate diet should be provided to meet the high metabolic demands. Low-calorie foods may not meet the calorie requirements of the patient and may lead to malnutrition and delayed wound healing. An adequate intake of fluids is essential for healing.
Which precautions would the nurse take when performing wound care on a burn patient? Select all that apply. The nurse wears personal protective equipment. The nurse wears the same gown and masks for all patients. The nurse uses nonsterile gloves when applying ointments. The nurse uses sterile gloves when applying sterile dressings. The nurse uses nonsterile gloves when removing contaminated dressings.
The nurse wears personal protective equipment. The nurse uses sterile gloves when applying sterile dressings. The nurse uses nonsterile gloves when removing contaminated dressings. Rationale The nurse wears personal protective equipment, such as a disposable gown, mask, and gloves, to prevent the spread of infection. The nurse uses sterile gloves when applying sterile dressings to prevent infection. The nurse uses nonsterile gloves when removing contaminated dressings for self-protection. The nurse should not wear the same gown and masks for all patients to avoid cross-contamination. It is necessary to wear new equipment before treating a new patient. The nurse should not necessarily use nonsterile gloves when applying ointments. Because the wound is open, sterile gloves should be used to prevent contamination.
A patient who sustained burn injuries is receiving daily wound treatments and tells the caregiver, "The nurses enjoy hurting me." Which would the nurse suspect? This patient must be having hallucinations. This patient might be having schizophrenia. This patient has a serious psychiatric condition. This is a normal reaction to an extraordinary life event.
This is a normal reaction to an extraordinary life event. Rationale Patients who have sustained burn injuries may experience a variety of emotions, including fear, anxiety, anger, guilt, and depression. The given example shows that the patient is angry and depressed, and it is important to reassure the patient and caregivers that these reactions may be normal and can be expected. The nurse should not assume from this reaction that the patient is experiencing hallucinations or any serious psychiatric conditions, including schizophrenia.
While caring for a patient with burns, a nurse wraps the patient's wound with tubular elastic gauze. Which are the reasons behind this action? Select all that apply. To decrease pain To prevent blistering To decrease itchiness To reduce venous return To enhance local immunity
To decrease pain To prevent blistering To decrease itchiness Rationale The interim pressure from tubular elastic gauze decreases pain and itchiness and prevents blistering. It promotes venous return rather than reducing it. It does not enhance local immunity.
Which actions would the nurse take to protect the eyes of a patient with partial-thickness burns on the face, including corneal burns? Select all that apply. Use antibiotic ointments. Wait for laboratory reports. Instill methylcellulose eyedrops. Arrange for ophthalmology examination. Inform the patient that periorbital edema is serious.
Use antibiotic ointments. Instill methylcellulose eyedrops. Arrange for ophthalmology examination. Rationale Eye care for corneal burns or edema includes antibiotic ointments. An ophthalmology examination should be conducted on all patients who have sustained facial burns. The use of methylcellulose drops or artificial tears is recommended for moisture and additional comfort. Waiting for laboratory reports does not help the patient; rather, the nurse can start the basic examination and treatment in the process just mentioned. Avoid giving any misleading information, such as telling the patient that periorbital edema is serious. This can frighten the patient and prevent eye opening. The nurse should assure the patient that the swelling is not permanent.
Which precautions would the nurse take when changing a burn wound dressing? Select all that apply. Use sterile gloves when removing a contaminated dressing. Use sterile gloves when applying ointments and sterile dressings. Wear nonsterile, disposable gloves when washing the dirty wound. Keep the room cool to decrease the burning sensation of the wound. Always wear personal protective equipment, such as masks, gowns, and gloves.
Use sterile gloves when applying ointments and sterile dressings. Wear nonsterile, disposable gloves when washing the dirty wound. Always wear personal protective equipment, such as masks, gowns, and gloves. Rationale The nurse should use sterile gloves when applying ointment and sterile dressings. Nonsterile, disposable gloves should be worn when removing contaminated dressings and washing a dirty wound. The nurse should always wear personal protective equipment before the burn wounds are exposed. The room should be kept warm to prevent shivering in the patient.
When instructing a community group about caring for a person with burns of more than 10% of total body surface area, which would the nurse advise? Select all that apply. Wrap the patient in a blanket. Gently remove burned clothing. Leave adherent clothing in place. Apply ice all over the burned area. Leave the affected area open to air.
Wrap the patient in a blanket. Gently remove burned clothing. Leave adherent clothing in place. Rationale In the case of severe burns, the patient should be wrapped in a blanket to avoid further contamination and to provide warmth. Burned clothing should be gently removed to prevent further tissue damage. Adherent clothing should be left in place until the patient is transferred to the hospital to avoid tissue damage. Leaving the affected area open to air can cause more contamination and is not advisable. Applying ice all over the burned area can cause hypothermia and is not advisable.
The nurse and health care provider plan to provide an antioxidant regimen for a patient with partial-thickness burns in the acute phase. Which antioxidants would the nurse identify as being included in the protocol? Select all that apply. Zinc Astaxanthin Chlorophyll Selenium Multivitamins
Zinc Selenium Multivitamins Rationale Zinc is an antioxidant and also a part of the antioxidant protocol because it supports cell growth and development. Selenium is used in the antioxidant protocol because it helps to prevent cell damage. Multivitamins are a part of the antioxidant protocol because they help to compensate for the nutritional deficiencies of essential vitamins and minerals. Astaxanthin and chlorophyll are antioxidants but are not a part of the antioxidant protocol. Calcium is important to maintain strong bones and teeth, but it is not included in the antioxidant protocol.
