Tissue Integrity

After receiving change-of-shift report, which of these patients should the nurse assess first? a. A patient with 40% total body surface area (TBSA) burns who is receiving IV fluids at 500 mL/hour b. A patient with smoke inhalation who has wheezes and altered mental status c. A patient with full-thickness leg burns who has a dressing change scheduled d. A patient with abdominal burns who is complaining of level 8 (0 to 10 scale) pain

B

On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 56%, Hb 17.2 mg/dL (172 g/L), serum K+ 4.8 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse anticipate taking? a. Continue to monitor the laboratory results. b. Increase the rate of the ordered IV solution. c. Type and crossmatch for a blood transfusion. d. Document the findings in the patient's record.

B

Which action will be included in the plan of care for a patient who has burns of the ears, head, neck, and right arm and hand? 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 rolled towel under the neck.

B

Which of these actions should the nurse take first when a patient arrives in the emergency department with facial and chest burns caused by a house fire? a. Infuse the ordered IV solution. b. Auscultate the patient's lung sounds. c. Determine the extent and depth of the burns. d. Administer the ordered opioid pain medications.

B

Which of these nursing actions should be done first for a patient who has suffered a burn injury while working on an electrical power line? a. Obtain the blood pressure. b. Stabilize the cervical spine. c. Assess for the contact points. d. Check alertness and orientation.

B

The nurse notes a bright red skin color for a patient who was found unconscious from smoke inhalation in a burning house. Which action should the nurse take first? a. Insert two large-bore IV lines. b. Check the patient's orientation. c. Place the patient on 100% oxygen using a non-rebreather mask. d. Assess for singed nasal hair and dark oral mucous membranes.

C

What is the priority nursing assessment when caring for a patient who has just arrived in the emergency department after suffering an electrical burn from exposure to a high-voltage current? a. Oral temperature b. Peripheral pulses c. Extremity movement d. Pupil reaction to light

C

A therapeutic measure used to prevent hypertrophic scarring during the rehabilitation phase of burn recovery is a. applying pressure garments. b. repositioning the patient every 2 hours. c. performing active ROM at least every 4 hours. d. massaging the new tissue with water-based moisturizers.

A

The RN observes all of the following actions being taken by a staff nurse who has floated to the unit. Which action requires that the RN intervene? a. The float nurse uses clean latex gloves when applying antibacterial cream to a burn wound. b. The float nurse obtains burn cultures when the patient has a temperature of 95.2° F (35.1° C). c. The float nurse administers PRN fentanyl (Sublimaze) IV to a patient 5 minutes before a dressing change. d. The float nurse calls the health care provider for an insulin order when a nondiabetic patient has an elevated serum glucose.

A

The injury that is least likely to result in a full-thickness burn is a. sunburn. b. scald injury. c. chemical burn. d. electrical injury.

A

To maintain a positive nitrogen balance in a major burn, the patient must a. eat a high-protein, high-carbohydrate diet. b. increase normal caloric intake by about three times. c. eat at least 1500 calories/day in small, frequent meals. d. eat a gluten-free diet for the chemical effect on nitrogen balance.

A

To maintain adequate nutrition for a patient who has just been admitted with a 40% total body surface area (TBSA) burn injury, the nurse will plan to a. insert a feeding tube and initiate enteral feedings. b. infuse total parenteral nutrition via a central catheter. c. encourage an oral intake of at least 5000 kcal per day. d. administer multiple vitamins and minerals in the IV solution.

A

After an employee spills industrial acids on the arms and legs at work, what is the priority action that the occupational health nurse at the facility should take? a. Apply an alkaline solution to the affected area. b. Place cool compresses on the area of exposure. c. Cover the affected area with dry, sterile dressings. d. Flush the burned area with large amounts of water.

D

Which of these patients is most appropriate for the burn unit charge nurse to assign to an RN staff nurse who has floated from the hospital medical unit? a. A 63-year-old patient who has blebs under an autograft on the thigh and has an order for bleb aspiration b. A 45-year-old patient who has just come back to the unit after having a cultured epithelial autograft to the chest c. A 60-year-old patient who has twice-daily burn debridements and dressing changes to partial-thickness facial burns d. A 34-year-old patient who has a weight loss of 15% from admission and requires enteral feedings and parenteral nutrition (PN)

D

In which order will the nurse take these actions when doing a dressing change for a partial-thickness burn wound on a patient's back? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. Apply sterile gauze dressing. b. Document wound appearance. c. Apply silver sulfadiazine cream. d. Administer IV fentanyl (Sublimaze). e. Clean wound with saline-soaked gauze.

D, E, C, A, B

When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the skin is red, swollen, and covered with large blisters. The patient states that they are very painful. The nurse will document the injury as a. full-thickness skin destruction. b. deep full-thickness skin destruction. c. deep partial-thickness skin destruction. d. superficial partial-thickness skin destruction.

C

During the emergent phase of burn care, which nursing action will be most useful in determining whether the patient is receiving adequate fluid infusion? a. Check skin turgor. b. Monitor daily weight. c. Assess mucous membranes. d. Measure hourly urine output.

D

Ranitidine (Zantac) is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which information will the nurse collect to evaluate the effectiveness of the medication? a. Bowel sounds b. Stool frequency c. Abdominal distention d. Stools for occult blood

D

A patient has 25% TBSA burn from a car fire. His wounds have been debrided and covered with a silver-impregnated dressing. The nurse's priority intervention for wound care would be to a. reapply a new dressing without disturbing the wound bed. b. observe the wound for signs of infection during dressing changes. c. apply cool compresses for pain relief in between dressing changes. d. wash the wound aggressively with soap and water three times a day.

A

A patient with circumferential burns of both arms develops a decrease in radial pulse strength and numbness in the fingers. Which action should the nurse take? a. Notify the health care provider. b. Monitor the pulses every 2 hours. c. Elevate both arms above heart level with pillows. d. Encourage the patient to flex and extend the fingers.

A

Pain management for the burn patient is most effective when (select all that apply) a. a pain rating tool is used to monitor the patient's level of pain. b. painful dressing changes are delayed until the patient's pain is completely relieved. c. the patient is informed about and has some control over the management of the pain. d. a multimodal approach is used (e.g., sustained-release and short-acting opioids, NSAIDs, adjuvant analgesics). e. nonpharmacologic therapies (e.g., music therapy, distraction) replace opioids in the rehabilitation phase of a burn injury.

A, C, D

When assessing a patient with a partial-thickness burn, the nurse would expect to find (select all that apply) a. blisters. b. exposed fascia. c. exposed muscles. d. intact nerve endings. e. red, shiny, wet appearance.

A, D, E

A patient is admitted to the burn unit with burns to the upper body and head after a garage fire. 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 the patient to cough and auscultate the lungs again. b. Notify the health care provider and prepare for endotracheal intubation. c. Document the results and continue to monitor the patient's respiratory rate. d. Reposition the patient in high-Fowler's position and reassess breath sounds.

B

A patient with deep partial-thickness and full-thickness burns of the face and chest is having the wounds treated with the open method. Which nursing action will be included in the plan of care? a. Restrict all visitors to prevent cross-contamination of wounds. b. Wear gowns, caps, masks, and gloves during all care of the patient. c. Turn the room temperature up to at least 68° F (20° C) during dressing changes. d. Administer prophylactic antibiotics to prevent bacterial colonization of wounds.

B

A patient with extensive electrical burn injuries is admitted to the emergency department. Which of these prescribed interventions should the nurse implement first? a. Start two large bore IVs. b. Place on cardiac monitor. c. Apply dressings to burned areas. d. Assess for pain at contact points.

B

A 21-year-old patient who is in the rehabilitation phase after having deep partial-thickness face and neck burns has a nursing diagnosis of disturbed body image. Which action by the patient indicates that the problem is resolving? a. Stating that the scarring will only be temporary. b. Avoiding using a pillow to prevent neck contractures. c. Asking about how to use make-up to cover up the scars. d. Expressing sadness and anger about the scar appearance.

C

A patient is recovering from second- and third-degree burns over 30% of his body and the burn care team is planning for discharge. The first action the nurse should take when meeting with the patient would be to a. arrange a return-to-clinic appointment and prescription for pain medications. b. teach the patient and the caregiver proper wound care to be performed at home. c. review the patient's current health care status and readiness for discharge to home. d. give the patient written information and websites for information for burn survivors.

C

A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be administered in the first 24 hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first 8 hours, the nurse will decrease the fluid infusion rate to a. 350 mL/hour. b. 523 mL/hour. c. 938 mL/hour. d. 1250 mL/hour.

C

Fluid and electrolyte shifts that occur during the early emergent phase of a burn injury include a. adherence of albumin to vascular walls. b. movement of potassium into the vascular space. c. sequestering of sodium and water in interstitial fluid. d. hemolysis of red blood cells from large volumes of rapidly administered fluid.

C

Knowing the most common causes of household fires, which prevention strategy would the nurse focus on when teaching about fire safety? a. Set hot water temperature at 140° F. b. Use only hardwired smoke detectors. c. Encourage regular home fire exit drills. d. Never permit older adults to cook unattended.

C

The nurse caring for a patient admitted with burns over 30% of the body surface will recognize that the patient has moved from the emergent to the acute phase of the burn injury when a. white blood cell levels decrease. b. blisters and edema have subsided. c. the patient has large quantities of pale urine. d. the patient has been hospitalized for 48 hours.

C

A patient is admitted to the burn center with burns to his head, neck, and anterior and posterior chest after an explosion in his garage. On assessment, the nurse auscultates wheezes throughout the lung fields. On reassessment, the wheezes are gone and the breath sounds are greatly diminished. Which action is the most appropriate for the nurse to take next? a. Encourage the patient to cough and auscultate the lungs again. b. Obtain vital signs, oxygen saturation, and a STAT arterial blood gas. c. Document the findings and continue to monitor the patient's breathing. d. Anticipate the need for endotracheal intubation and notify the physician.

D

A patient who has burns on the back and chest from a house fire has become agitated and restless 9 hours after being admitted to the hospital. Which action should the nurse take first? a. Stay at the bedside and reassure the patient. b. Administer the ordered morphine sulfate IV. c. Assess orientation and level of consciousness. d. Use pulse oximetry to check the oxygen saturation.

D

Six hours after a thermal burn covering 50% of a patient's total body surface area (TBSA), the nurse obtains these data when assessing a patient. What is the priority information to communicate to the health care provider? a. Blood pressure is 94/46 per arterial line. b. Serous exudate is leaking from the burns. c. Cardiac monitor shows a pulse rate of 104. d. Urine output is 20 mL per hour for the past 2 hours.

D

Which of these laboratory results requires the most rapid action by the nurse who is caring for a patient who suffered a large burn 48 hours ago? a. Hct 52% b. BUN 36 mg/dL c. Serum sodium 146 mEq/L d. Serum potassium 6.2 mEq/L

D

Which of these medications that are prescribed as needed for a patient who has partial thickness burns will be best for the nurse to use before wound debridement? a. ketorolac (Toradol) b. lorazepam (Ativan) c. gabapentin (Neurontin) d. hydromorphone (Dilaudid)

D

Which of these snacks will be best for the nurse to offer to a patient with burns covering 40% total body surface area (TBSA) who is in the acute phase of burn treatment? a. Strawberry gelatin b. Whole wheat bagel c. Chunky applesauce d. Chocolate milkshake

D