BURNS

The burn nurse is aware that wound care during the acute phase involves consideration of which of the following?

a. First and superficial second-degree burns can usually be managed with clean technique.

b. Deep second-degree burns with or without impaired circulation heal without surgical intervention.

c. Full thickness burns require surgical intervention to heal.

d. The presence of infection is a contraindication to surgical wound management.

c. Full thickness burns require surgical intervention to heal.

During the rehabilitation phase, the physical healing focuses primarily on wound healing. The burn nurse includes which the following in patient education to assist the patient and family for their return to the community?

a.The immune system heals along with the skin and future risk of infection stabilizes.

b. The hypermetabolic state lasts from 9-12 months following burn injury and body weight requires carefully monitoring.

c. Extensive burn injury decreases the risk for developing bone density changes.

d. Thermoregulation disturbances may result in an inability to adjust to changes in environment temperatures.

b. The hypermetabolic state lasts from 9-12 months following burn injury and body weight requires carefully monitoring.

When evaluating the burn extremity for the development of compartment syndrome, which signs and symptoms would alert the nurse to the possibility this has developed??

a.The presence of burn eschar that covers the entire lateral surface of the extremity.

b. There is evidence of tautness, decreased capillary refill, coolness and decreased pulses.

c. The edema is the area is rapidly dissipating resulting in hypoperfusion to the extremity.

d. There is increased discomfort in the affected area.

b. There is evidence of tautness, decreased capillary refill, coolness and decreased pulses.

While monitoring a burn victim, which of the following is considered the 'gold standard' to evaluate burn resuscitation?

a. A heart rate less than 120 beats per minute, a blood pressure that is normal to slightly hypertensive and clear lung sounds.

b. An adult urine output that is approximately 0.5-1.0ml/kg/hour.

c. A pulmonary capillary wedge pressure of less than 18 mm Hg.

d. A urinary output has been adequate for 2 hours.

b. An adult urine output that is approximately 0.5-1.0ml/kg/hour

Using the Parkland formula calculate the fluid volume for a 154 woman who has sustained a 36% mixed deep partial and full thickness burn. How much fluid would you administer during the first 8 hours of fluid resuscitation?

a.10,080 milliliters.

b. 20,160 milliliters.

c. 5,040 milliliters.

d. 2520 milliliters.

c. 5,040 milliliters

Which of the following nursing diagnoses for the patient with a burn Injury has the highest priority during the resuscitative phase?

a. Impaired Gas Exchange related to inhalation injury.

b. Ineffective airway clearance related to inhalation injury.

c. Deficient fluid Volume related to third spacing of fluids.

d. Pain related to burn injury.

b. Ineffective airway clearance related to inhalation injury.

The nurse is performing a primary burn assessment according to the ABCs (airway, breath, circulation) guidelines. Which of the following indicate signs and symptoms of inhalation injury?

a.Facial swelling and bruising.

b. Progressive stridor and hoarseness.

c. Singed chest hairs.

d. Increased body temperature.

b. Progressive stridor and hoarseness

The nurse is assessing an Emergency Room patient for evidence of cardiovascular changes associated with deep and full thickness burns. Which of the following would indicate cardiovascular changes as a result of a serious burn?

a. Edema formation can be expected in the burn area as a compensatory process from the microcirculation.

b. Hypovolumia, slowed capillary circulation and hyperviscosity are evident.

c. Increased tissue perfusion in the wound area to attempt to maintain tissue viability in the affected area.

d. Peripheral vasodilation decreases perfusion in the affected area.

b. Hypovolumia, slowed capillary circulation and hyperviscosity are evident

Which of the following dysfunctions can the nurse anticipate in the burn patient with deep partial or full thickness injury?

a. There is retention of the ability of the skin to regulate core temperature.

b. There is increased risk of infection due to a loss of integrity of a primary barrier.

c. There is a decreased sensitivity to ultraviolet radiation.

d. There is maintenance of the ability to absorb Vitamin D.

b. There is increased risk of infection due to a loss of integrity of a primary barrier

The nurse is assessing a patient who has sustained a suspected deep partial thickness burn. In determining if this is a superficial or deep partial thickness injury, the nurse would anticipate which of the following? (Select all that apply.)

a. There is no change in capillary refill in the injured extremity.

b. Hair follicles, sebaceous glands and epidermal sweat glands are intact.

c. The wound appearance is a waxy white, with a wet surface and fluid filled blisters.

d. The wound is very painful.

c. The wound appearance is a waxy white, with a wet surface and fluid filled blisters.

The nurse is caring for a client with an electrical burn. Which structures have the greatest risk for soft tissue injury?

A. Fat, tendons, and bones

B. Skin and hair

C. Nerves, muscle, and blood vessels

D. Skin, fat, and muscle

A. Fat, tendons, and bones

Which laboratory result would be expected during the emergent phase of a burn injury?

A. Glucose 100 mg/dL

B. Potassium 3.5 mEq/L

C. Sodium 142 mEq/L

D. Albumin 4.2 gm/dL

A. Glucose 100 mg/dL

An African American client is admitted with full thickness burns over 40% of his body. In addition to the CBC and complete metabolic panel, the physician is likely to request which additional blood-work?

A. Erythrocyte sedimentation rate

B. Indirect Coombs

C. C reactive protein

D. Sickledex

D. Sickledex

A client weighing 76 kg is admitted at 0600 with a TBSA burn of 40%. Using the Parkland formula, the client's 24-hour intravenous fluid replacement should be:

A. 6,080 mL

B. 9,120 mL

C. 12,160 mL

D. 15,180 mL

C. 12,160 mL

On the third post-burn day, the nurse finds that the client's hourly urine output is 26 ml. The nurse should continue to assess the client and notify the doctor for an order to:

A. Decrease the rate of the intravenous infusion.

B. Change the type of intravenous fluid being administered.

C. Change the urinary catheter.

D. Increase the rate of the intravenous infusion.

D. Increase the rate of the intravenous infusion

A Jewish client requires grafting to promote burn healing. Which graft is most likely to be unacceptable to the client?

A. Isograft

B. Autograft

C. Homograft

D. Xenograft

D. Xenograft

During the rehabilitative phase, the client's burns become infected with pseudomonas. The topical dressing most likely to be ordered for the client is:

A. Silver sulfadiazine (Silvadene)

B. Poviodine (Betadine)

C. Mafenide acetate (Sulfamylon)

D. Silver nitrate

C. Mafenide acetate (Sulfamylon)

The CVP reading of a client with partial thickness burns is 6 mm H2O. The nurse recognizes that the client:

A. Needs additional fluids

B. Has a normal CVP reading

C. May show signs of congestive failure

D. Would benefit from a diuretic

B. Has a normal CVP reading

The physician has prescribed Protonix (pantoprazole) for a client with burns. The nurse recognizes that the medication will help prevent the development of:

A. Curling's ulcer

B. Myoglobinuria

C. Hyperkalemia

D. Paralytic ileus

A. Curling's ulcer

The nurse has just completed the dressing change for a client with burns to the lower legs and ankles. The nurse should place the client's ankles in which position?

A. Internal rotation

B. Abduction

C. Dorsiflexion

D. Hyperextension

C. Dorsiflexion

1. A patient is brought to the Emergency Department from the site of a chemical fire. The paramedics report that the patient has a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. When you assess the patient he verbalizes no pain in the right arm and the skin appears charred. Based upon these assessment findings, what is the depth of the burn on the patient's right arm?

A) Superficial partial-thickness

B) Deep partial-thickness

C) Full partial-thickness

D) Full-thickness

FULL THICKNESS

**A full-thickness burn involves total destruction of the epidermis and dermis and, in some cases, underlying tissue as well. Wound color ranges widely from white to red, brown, or black. The burned area is painless because the nerve fibers are destroyed. The wound can appear leathery; hair follicles and sweat glands are destroyed. Edema may also be present. Full partial thickness is not a depth of burn. Superficial partial-thickness burns involve the epidermis and possibly a portion of the dermis and the patient will experience pain that is soothed by cooling. Deep partial-thickness burns involve the epidermis, upper dermis, and portion of the deeper dermis and the patient will complain of pain and sensitivity to cold air.

2. The nursing instructor is going over burn

injuries. The instructor tells the students that the nursing care priorities for a patient with a burn injury include wound care, nutritional support, and prevention of complications such as infection. Based upon these care priorities, the instructor is most likely discussing a patient in what phase of burn care?

A) Emergent

B) Immediate resuscitative

C) Acute

D) Rehabilitation

ACUTE

**The acute or intermediate phase of burn care

follows the emergent/resuscitative phase and begins 48 to 72 hours after the burn injury. During this phase, attention is directed toward continued assessment and maintenance of respiratory and circulatory status, fluid and electrolyte balance, and gastrointestinal function. Infection prevention, burn wound care (ie, wound cleaning, topical antibacterial therapy, wound dressing, dressing changes, wound debridement, and wound grafting), pain management, and nutritional support are priorities at this stage and are discussed in detail in the following sections. Priorities during the emergent or immediate resuscitative phase include first aid, prevention of shock and respiratory distress, detection and treatment of concomitant injuries, and initial wound assessment and care. The priorities during the rehabilitation phase include prevention of scars and contractures, rehabilitation, functional and cosmetic reconstruction, and psychosocial counseling.

3. A patient in the emergent/resuscitative phase of a burn injury has had her lab work drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what?

A) Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis

B) Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis

C) Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis

D) Hypokalemia, hyponatremia, elevated hematrocrit, and metabolic alkalosis

HYPERKALEMIA, HYPONATREMIA, ELEVATED HEMATOCRIT AND METABOLIC ACIDOSIS

**Fluid and electrolyte changes in the emergent/resuscitative phase of a burn injury include hyperkalemia related to the release of potassium into the extracellular fluid, hyponatremia from large amount of sodium lost in trapped edema fluid, hemoconcentration that leads to an increased hematocrit, and loss of bicarbonate ions that results in metabolic acidosis.

4. The patient you are caring for has an electrical burn and has developed thick eschar over the burn wound. Which of the following topical antibacterial agents will the nurse expect the physician to order for the wound?

A) Silver sulfadiazine 1% (Silvadene) water-soluble cream

B) Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream

C) Silver nitrate 0.5% aqueous solution

D) Acticoat

MAFENIDE ACETATE 10% (SULFAMYLON) HYDROPHILIC-BASED CREAM

**Mafenide acetate 10% hydrophilic-based cream is

the agent of choice for electrical burns because of its ability to penetrate thick eschar.

5. The occupational health nurse is called to

the floor of the factory where a patient has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to "cool the burn." How will the nurse cool the burn?

A) Apply ice to the site of the burn for 5 to 10 minutes.

B) Wrap the patient's affected extremity in ice until help arrives.

C) Apply an oil-based substance or butter to the burned area until help arrives.

D) Wrap cool towels around the affected extremity intermittently.

WRAP COOL TOWELS AROUND AFFECTED EXTREMITY INTERMITTANTLY

**Once the burn has been sustained, the application

of cool water is the best first-aid measure. Soaking the burn area intermittently in cool water or applying cool towels gives immediate and striking relief from pain and limits local tissue edema and damage. However, never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns.

6. The emergency department nurse has just admitted a patient with a burn. The nurse recognizes that the patient is likely to experience a local and systemic response to the burn when the burn exceeds a total body surface area (TBSA) of what?

A) 10%

B) 15%

C) 20%

D) 25%

25%

**If the burn exceeds 20% to 25% TBSA, a nasogastric tube is inserted and connected to low intermittent suction. Often, patients with large burns become nauseated as a result of the gastrointestinal effects of the burn injury, such as paralytic ileus, and the effects of medication such as opioids. All patients who are intubated should have a nasogastric tube inserted to decompress the stomach and prevent vomiting.

7. The nurse on a burn unit is caring for a

patient in the acute phase of burn care. While performing an assessment during this phase of burn care, the nurse recognizes that airway obstruction related to upper airway edema may occur up to how long after the burn injury?

A) 2 days

B) 3 days

C) 5 days

D) A week

2 DAYS

**Airway obstruction caused by upper airway edema can take as long as 48 hours to develop. Changes detected by x-ray and arterial blood gases may occur as the effects of resuscitative fluid and the chemical reaction of smoke ingredients with lung tissues become apparent.

8. A patient has sustained a severe burn

injury and is thought to have an impaired intestinal mucosal barrier. Since this patient is considered at an increased risk for infection, what intervention will assist in avoiding increased intestinal permeability and prevent early endotoxin translocation?

A) Early enteral feeding

B) Administration of prophylactic antibiotics

C) Bowel cleansing procedures

D) Administration of stool softeners

EARLY AND ENTERAL FEEDING

**If the intestinal mucosa receives some type of protection against permeability change, infection could be avoided. Early enteral feeding is one step to help avoid this increased intestinal permeability and prevent early endotoxin translocation. Antibiotics are seldom prescribed prophylactically because of the risk of promoting resistant strains of bacteria. A bowel cleansing procedure would not be ordered for this patient. The administration of stool softeners would not assist in avoiding increased intestinal permeability and prevent early endotoxin translocation.

9. A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. What would be the nurse's priority concern about this patient?

A) Fluid status

B) Risk of infection

C) Body image

D) Level of pain

FLUID STATUS

**During the early phase of burn care, the nurse is most concerned with fluid resuscitation, to correct large-volume fluid loss through the damaged skin. Infection, body image, and pain are significant areas of concern, but are less urgent than fluid status.

10. The nurse is preparing the patient for mechanical debridement and informs the patient that this will involve:

A) A spontaneous separation of dead tissue from the viable tissue

B) Use of surgical scissors, scalpels or forceps to remove the eschar until the point of pain and bleeding occurs

C) Shaving of burned skin layers until bleeding, viable tissue is revealed

D) Early closure of the wound

USE OF SURGICAL SCISSORS, SCALPELS OR FORCEPS TO REMOVE THE ESCHAR UNTIL THE POINT OF PAIN AND BLEEDING OCCURS

**Mechanical debridement can be achieved through the use of surgical scissors, scalpels, or forceps to remove the eschar until the point of pain and bleeding occurs. Mechanical debridement can also be accomplished through the use of topical enzymatic debridement agents. The spontaneous separation of dead tissue from the viable tissue is an example of natural debridement. Early wound closure and shaving the burned skin layers are examples of surgical debridement.

11. A patient with a partial-thickness burn injury had Biobrane applied 2 weeks ago. The nurse notices that the Biobrane is separating from the burn wound. What is the appropriate nursing intervention when this separation occurs?

A) Reinforce the Biobrane dressing with another piece of Biobrane.

B) Remove the Biobrane dressing and apply a new dressing.

C) Trim away the separated Biobrane.

D) Notify the physician for further emergency related orders.

TRIM AWAY THE SEPARATED BIOBRANE

**As the Biobrane gradually separates, it is trimmed, leaving a healed wound. When the Biobrane dressing adheres to the wound, the wound remains stable and the Biobrane can remain in place for 3 to 4 weeks. You would not reinforce the Biobrane, or remove it and apply a new dressing. Nor would you notify the physician for further orders.

12. An emergency department nurse learns from the paramedics that they are transporting a patient who has suffered injury from a scald from a hot kettle. What factors does the nurse know are considered when determining the depth of burn?

A) Causative agent

B) Visual observation of burned area

C) Area of body burned

D) Circumstances of the accident

CAUSATIVE AGENT

**The following factors are considered in determining the depth of a burn: how the injury occurred, causative agent (such as flame or scalding liquid), temperature of the burning agent, duration of contact with the agent, and thickness of the skin. To determine the depth of the burn you do not take into consideration you visual observation of the burned area, how much of the body is burned, or the circumstances of the accident.

13. The nurse is caring for a patient who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis?

A) Activity intolerance

B) Anxiety

C) Impaired nutrition: less than body requirements

D) Acute pain

ACUTE PAIN

**Pain is inevitable during recovery from any burn injury. Pain in the burn patient has been described as one of the most severe causes of acute pain. Management of the often-severe pain is one of the most difficult challenges facing the burn team. While the other nursing diagnoses listed are valid diagnoses, the presence of pain may contribute to these diagnoses and management of the patient's pain is priority as it may have a direct correlation to these nursing diagnoses.

14. The triage nurse in the emergency department (ED) receives a phone call from a frantic father who saw his 4-year-old child tip a pot of boiling water onto her chest. The father has called an ambulance. What would the nurse in the ED receiving the call instruct the father to do?

A) Cover the burn with ice and secure with a towel.

B) Apply butter to the area that is burned.

C) Immerse the child in a cool bath.

D) Avoid touching the burned area and seek medical attention.

IMMERSE THE CHILD IN A COOL BATH

**After the flames or heat source have been removed or extinguished, the burned area and adherent clothing are soaked with cool water briefly to cool the wound and halt the burning process. Cool water is the best first-aid measure. You do not put ice on the burn, nor do you put butter on the burn. You do not need to avoid touching the burn.

15. The nurse is teaching a patient with a partial-thickness wound how to wear his elastic pressure garment. How would the nurse instruct the patient to wear this garment?

A) 4 to 6 hours a day for 6 months

B) Daily for 2 to 3 months after the injury

C) Continuously

D) At night while sleeping for a year after the injury

CONTINUOUSLY

Garments are worn continuously (ie, 23 hours a day).

16. A patient is brought to the ED by paramedics who report the patient has partial-thickness burns on the chest and legs. The patient has also suffered smoke inhalation. What is a priority in the care of a patient who has been burned and suffered smoke inhalation?

A) Pain

B) Fluid balance

C) Anxiety and fear

D) Airway management

AIRWAY MANAGEMENT

**Systemic threats from a burn are the greatest threat to life. The ABCs of all trauma care apply during the early postburn period. While all options should be addressed, pain, fluid balance, and anxiety and fear do not take precedence over airway management.

17. A patient arrives in the emergency department after being burned in a house fire. The patient's burns cover the face and the left forearm. What percentage of burn does the patient have?

A) 10%

B) 25%

C) 9%

D) 18%

18%

**When estimating the percentage of body area or burn surface area that has been burned, the Rule of Nines is used: the face is 9%, and the forearm is 9% for a total of 18% in this patient.

18. The nursing instructor is teaching about the emergent/resuscitative phase of burn injury. During this phase, what would the nursing instructor tell the students they should closely monitor in the laboratory values?

A) Sodium deficit

B) Bleeding time

C) Potassium deficit

D) Decreased hematocrit

SODIUM DEFICIT

**Anticipated fluid and electrolyte changes that occur during the emergent/resuscitative phase of burn injury include potassium excess, sodium deficit, base-bicarbonate deficit, and elevated hematocrit.

19. The nursing students are doing clinical hours on the burn unit. A nurse is developing a care plan for a patient with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. A nursing student asks why this goal is important when the patient is fighting for his life. What should the burn nurse respond?

A) To prevent neuropathies

B) To prevent wound breakdown

C) To prevent contractures

D) To prevent heterotopic ossification

PREVENT CONTRACTURES

**To prevent the complication of contractures the nurse will establish a goal to maintain position of joints in alignment. Gentle range of motion exercises and a consult to PT and OT for exercises and positioning recommendations are also appropriate interventions for the prevention of contractures.

20. Grafts taken from one body and grafted onto another body are called what?

A) Allograft

B) Homograft

C) Heterograft

D) Autograft

HOMOGRAFT

**Homografts are grafts derived from one person's body and used on another part of a different person's body.

21. A nurse taking care of a burn patient is asked why the patient is losing so much weight. What would be the nurse's most appropriate answer?

A) "Your body has built up extra fat deposits even though you haven't been eating very much."

B) "Your body has used your fat deposits for fuel because you haven't been eating very much."

C) Your reserve fat deposits have been catabolized because you have been eating so much."

D) You have lost fluids and you haven't eaten very much."

YOUR BODY HAS USED YOUR FAT DEPOSITS FOR FUEL BECAUSE YOU HAVEN'T BEEN EATING VERY MUCH

**Patients lose a great deal of weight during recovery from severe burns. Reserve fat deposits are catabolized, fluids are lost, and caloric intake may be limited.

22. Where do most burn injuries occur?

A) On the road

B) At home

C) At work

D) Recreational accidents

AT HOME

** Of those people admitted to burn centers, 47% are injured at home, 27% on the road, 8% are occupational, 5% are recreational, and the remaining 13% are from other sources.

23. A 45-year-old man is brought in by Life-Flight after a motor vehicle accident is which he was trapped in a burning vehicle. The burn team is estimating the patient's likelihood of survival based on the severity of the burn injury. The emergency department nurse knows that the severity of the injury is based on what factors? (Mark all that apply.)

A) Age

B) Depth of the burn

C) Presence of inhalation injury

D) Family support

E) Psychological state of the patient

A, B, C

AGE, DEPTH OF THE BURN, PRESENCE OF INHALATION INJURY

**The severity of each burn injury is determined by multiple factors that when assessed help the burn team estimate the likelihood that a patient will survive and plan the care for each patient. These factors include age of the patient; depth of the burn; amount of surface area of the body that is burned; presence of inhalation injury; presence of other injuries; location of the injury in special care areas such as the face, perineum, hands, and feet; and presence of a past medical history. Options D and E are not factors that bear on the severity of the injury.

24. You have just reported to the burn unit to start your shift. Four new patients have been admitted in the past 12 hours. Which patient is most likely to have life-threatening complications?

A) A 4-year-old scald victim burned over 24% of the body

B) A 27-year-old healthy male burned over 36% of his body in a car accident

C) A 39-year-old female with myasthenia gravis burned over 18% of her body

D) A 60-year-old male burned over 16% of his body in a brush fire

A 4 YEAR OLD SCALD VICTIM BURNED OVER 24% FO THE BODY

**Young children and the elderly continue to have increased morbidity and mortality when compared to other age groups with similar injuries and present a challenge for burn care. This is an important factor when determining the severity of injury and possible outcome for the patient.

25. A burn patient is brought to the emergency department. The nurse knows that the first systemic event after a major burn injury is what?

A) Hemodynamic instability

B) Metabolic acidosis

C) Hypovolemia

D) Hyperkalcemia

HEMODYNAMIC INSTABILITY

**The initial systemic event after a major burn injury is hemodynamic instability, which results from loss of capillary integrity and a subsequent shift of fluid, sodium, and protein from the intravascular space into the interstitial spaces. Options B, C, and D occur, they are just not the first event to happen.

26. A burn victim is admitted to the Intensive Care Unit to stabilize and begin fluid resuscitation before transport to the burn center. If inadequate fluid resuscitation occurs what happens to the patient?

A) Becomes unresponsive

B) Distributive shock

C) Death

D) Hypovolemic shock

DISTRIBUTIVE SHOCK

Prompt fluid resuscitation maintains the blood pressure in the low-normal range and improves cardiac output. Despite adequate fluid resuscitation, cardiac filling pressures (central venous pressure, pulmonary artery pressure, and pulmonary artery wedge pressure) remain low during the burn-shock period. If inadequate fluid resuscitation occurs, distributive shock occurs

27. An emergency department nurse has just received a burn victim brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the patient's body. The nurse knows that pathophysiologic changes resulting from major burns during the initial burn-shock period include what?

A) Hyper-dynamic anabolism

B) Hyper-metabolic catabolism

C) Decreased cardiac output

D) Organ hyper-function

DECREASED CARDIAC OUTPUT

**Pathophysiologic changes resulting from major burns during the initial burn-shock period include tissue hypo-perfusion and organ hypo-function secondary to decreased cardiac output, followed by a hyper-dynamic and hyper-metabolic phase. Options A and B are distracters for this question.

28. A male patient, 16 years old, comes to the emergency department (ED) after burning his right hand and arm while working on a friend's car. The injury is determined to be a superficial burn and it is treated. What would the nurse teach the patient before discharging him home to return on a daily basis for dressing changes?

A) "As your arm swells, push on your fingernails. If it takes longer than 5 seconds for them to get pink come back to the ED."

B) "You should be fine until you come back tomorrow for your dressing change."

C) "Drink lots of fluids and elevate the arm."

D) "The burned area will start to swell in about 4 hours and blisters will form. If you think the dressing is too tight come back to the ED."

"The burned area will start to swell in about 4 hours and blisters will form. If you think the dressing is too tight come back to the ED."

**In a superficial burn there is loss of capillary integrity and fluid is localized to the burn itself, resulting in blister formation and edema only in the area of injury. Capillary refill should be 3 seconds or less. Options B and C are distracters for this question.

29. A patient is admitted to the burn unit after being transported from a facility 1000 miles away. The patient has burns to the groin area and both legs. The burns to the lower legs are circumferential. The nurse knows to monitor closely for what as the edema in this patient increases?

A) Ischemia

B) Eschar

C) Hyper-profusion to the burned area

D) Increased fluid loss through the burned area

ISCHEMIA

**As edema increases, pressure on small blood vessels and nerves in the distal extremities causes an obstruction of blood flow and consequent ischemia. This complication is similar to compartment syndrome. The physician may need to perform an escharotomy, a surgical incision into the eschar (devitalized tissue resulting from a burn), to relieve the constricting effect of the burned tissue.

30. A nurse on the burn unit is caring for a patient who has gone into the acute phase of her burn. What would be important for the nurse to monitor the patient for?

A) Hypometabolism

B) Hyponatremia

C) Hyperkalemia

D) Hypoglycemia

HYPONATREMIA

**Hyponatremia is common during the first week of the acute phase, as water shifts from the interstitial space to the vascular space. Hypermetabolism can occur up to 1 year after the burn. Hyperkalemia occurs in the emergent phase of the burn. In a burn patient there is a hyperglycemic response, not a hypoglycemic response.

31. The acute phase of the burn begins 48 to 72 hours after the burn. What begins at this time?

A) Cardiac output decreases

B) Renal failure begins

C) Diuresis

D) Fluid moves from intravascular compartment to interstitial spaces

DIURESIS

**As capillaries regain integrity, 48 or more hours after the burn, fluid moves from the interstitial to the intravascular compartment and diuresis begins. Cardiac output should increase and renal output should increase.

32. As the patient begins the acute phase of a burn, cautious administration of fluids and electrolytes continues. The nurse knows that this caution is because of what? (Mark all that apply.)

A) Patient is considered in critical condition

B) Cardiac function is decreased

C) Patient's physiologic responses to the burn injury

D) Losses of fluid from large burn wounds

E) Shifts in fluid from the interstitial to the intravascular compartment

C) Patient's physiologic responses to the burn injury

D) Losses of fluid from large burn wounds

E) Shifts in fluid from the interstitial to the intravascular compartment

**Cautious administration of fluids and electrolytes continues during this phase of burn care because of the shifts in fluid from the interstitial to the intravascular compartment, losses of fluid from large burn wounds, and the patient's physiologic responses to the burn injury.

33. What is the nursing goal during the acute phase of a burn?

A) To ultimately prevent or control infection in the burn population

B) To prevent hypervolemia in the burn population

C) To manage pain in a proactive way for the patient's comfort

D) To provide emotional support as the changes in body image become internalized in the patient

TO ULTIMATELY PREVENT OR CONTROL INFECTION IN THE BURN POPULAITON

**The nursing goal is to provide protection and safety in the patients' environment to ultimately prevent or control infection in the burn population. This makes options B, C, and D incorrect.

34. A nurse is caring for a patient during the acute phase of the burn. The nurse knows he is responsible for what?

A) Restricting visitors to prevent infection

B) Closely scrutinizing the burn wound to detect early signs of infection

C) Cleaning the patient's room

D) Maintaining the patient in a sterile environment

CLOSELY SCRUTINIZING THE BURN WOUND TO DETECT EARLY SIGNS OF INFECTION

**The nurse is responsible for providing a clean and safe environment and for closely scrutinizing the burn wound to detect early signs of infection. Visitors are not restricted to a burn patient. The nurse does not clean the patient's room. The patient is maintained in a clean environment, not a sterile environment.

35. It is time to change the dressings on a burn patient. What does the nurse do to reduce pain and discomfort at this time?

A) The nurse lets the patient decide on when to change the dressing.

B) The nurse skip's the dressing change if the patient is really uncomfortable.

C) The nurse changes dressings as quickly as possible.

D) The nurse lets the aide do the painful part of the dressing change.

THE NURSE CHANGES DRESSINGS AS QUICKLY AS POSSIBLE

**The nurse works quickly to complete treatments and dressing changes to reduce pain and discomfort. Letting the patient decide the time of the dressing change lets the patient feel more in control. It doesn't reduce pain and discomfort. The nurse should never skip an ordered dressing change. You never delegate a dressing change on a burn patient.

36. You are caring for a burn patient who is in the later stages of the acute phase of the burn injury. What is an important factor in your care of the patient?

A) Immobilizing the patient

B) Maintaining splints and functional devices

C) Maintaining ongoing discussion about the patient with a psychologist

D) Prevention of DVT

PREVENTION OF DVT

**Prevention of deep vein thrombosis (DVT) is an important factor in care. Early mobilization of the patient is important. The nurse monitors the splints and functional devices, but does not maintain them. The nurse does not maintain discussion with a psychologist about the patient.

37. Your patient is in the acute phase of a burn injury. One of the nursing diagnoses on the plan of care is ineffective coping due to burn injury and altered body image. What interventions can you institute to help this patient cope more effectively? (Mark all that apply.)

A) Promote truthful communication

B) Allowing the patient to set specific expectations

C) Assist the patient in practicing appropriate strategies

D) Stop the patient's manipulation of staff

E) Give positive reinforcement when appropriate

A,C,E

PROMOTE TRUTHFUL COMUNICATION, ASSIST THE PATIENT IN PRACTICING APPROPRIATE STRATEGIES, GIVE POSITIVE REINFORCEMENT WHEN APPROPRIATE

**The nurse can assist the patient to develop effective coping strategies by setting specific expectations for behavior, promoting truthful communication to build trust, helping the patient practice appropriate strategies, and giving positive reinforcement when appropriate. The nurse should set specific expectations, not the patient. Each staff member needs to stop the manipulation of the patient with the involved staff member.

38. What is a priority in the rehabilitation phase of the burn injury?

A) Monitoring fluid and electrolyte imbalances

B) Patient and family education

C) Assessing wound healing

D) Documenting family support

PATIENT AND FAMILY EDUCATION

**Patient and family education is a priority in the acute and rehabilitation phases. There should be no fluid and electrolyte imbalances in the rehabilitation phase. Assessing wound healing is an ongoing function but it is not a priority in the rehabilitation phase. Documenting family support is not a priority in the rehabilitation phase.

39. A burn patient is transitioning from the acute phase of the injury to the rehabilitation phase. The patient tells the nurse "I can't wait to have surgery to reconstruct my face so I look normal again." What would be the nurse's best response?

A) "You know, nothing can be done until your scars mature. It is something the doctor will talk to you about in the first few years after discharge."

B) "That is something for you to talk to your doctor about."

C) "I know this is really important to you, but you have to realize that no one can make you look like you used to."

D) "You will have most of these scars for the rest of your life."

YOU KNOW, NOTHING CAN BE DONE UNTIL YOUR SCARS MATURE. IT IS SOMETHING THE DOCTOR WILL TALK TO YOU ABOUT IN THE FIRST FEW YEARS AFTER DISCHARGE

**Burn reconstruction is a treatment option after all scars have matured and is discussed within the first few years after injury. Options B and C are true statements but not the best statements. The nurse does not know for sure how much reconstruction can be done.

40. A patient in the rehabilitation phase of the burn injury is setting goals with the nurse. What goals would be appropriate at this time? (Mark all that apply.)

A) Increased participation in activities of daily living

B) Increased understanding of the planned follow-up care

C) Increased control of treatment

D) Adjustment to alterations in lifestyle

E) Recognition of complications

A, B, D

INCREASED PARTICIPATION IN ADLs, INCREASED UNDERSTANDING OF THE PLANNED FOLLOW-UP CARE, ADJUSTMENT TO ALTERATIONS IN LIFESTYLE

**The major goals for the patient include increased participation in activities of daily living; increased understanding of the injury, treatment, and planned follow-up care; adaptation and adjustment to alterations in body image, self-concept, and lifestyle; and absence of complications.

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

ANS: B

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

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 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse anticipate taking now?

a. Monitor urine output every 4 hours.

b. Continue to monitor the laboratory results.

c. Increase the rate of the ordered IV solution.

d. Type and crossmatch for a blood transfusion.

ANS: C

The patient's laboratory data show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Because the hematocrit and hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase once the patient's fluid balance has been restored. On admission to a burn unit, the urine output would be monitored more often than every 4 hours; likely every1 hour.

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 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.

ANS: B

The patient's history and clinical manifestations suggest airway edema and the health care provider should be notified immediately, so that intubation can be done rapidly. Placing the patient in a more upright position or having the patient cough will not address the problem of airway edema. Continuing to monitor is inappropriate because immediate action should occur

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, what rate should the nurse infuse the IV fluids?

a. 350 mL/hour

b. 523 mL/hour

c. 938 mL/hour

d. 1250 mL/hour

ANS: C

Half of the fluid replacement using the Parkland formula is administered in the first 8 hours and the other half over the next 16 hours. In this case, the patient should receive half of the initial rate, or 938 mL/hr.

During the emergent phase of burn care, which assessment 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.

ANS: D

When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hour. The patient's weight is not useful in this situation because of the effects of third spacing and evaporative fluid loss. Mucous membrane assessment and skin turgor also may be used, but they are not as adequate in determining that fluid infusions are maintaining adequate perfusion.

A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain adequate nutrition, the nurse should plan to take which action?

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.

ANS: A

Enteral feedings can usually be initiated during the emergent phase at low rates and increased over 24 to 48 hours to the goal rate. During the emergent phase, the patient will be unable to eat enough calories to meet nutritional needs and may have a paralytic ileus that prevents adequate nutrient absorption. Vitamins and minerals may be administered during the emergent phase, but these will not assist in meeting the patient's caloric needs. Parenteral nutrition increases the infection risk, does not help preserve gastrointestinal function, and is not routinely used in burn patients.

While the patient's full-thickness burn wounds to the face are exposed, what is the best nursing action to prevent cross contamination?

a. Use sterile gloves when removing old dressings.

b. Wear gowns, caps, masks, and gloves during all care of the patient.

c. Administer IV antibiotics to prevent bacterial colonization of wounds.

d. Turn the room temperature up to at least 70° F (20° C) during dressing changes.

ANS: B

Use of gowns, caps, masks, and gloves during all patient care will decrease the possibility of wound contamination for a patient whose burns are not covered. When removing contaminated dressings and washing the dirty wound, use nonsterile, disposable gloves. The room temperature should be kept at approximately 85° F for patients with open burn wounds to prevent shivering. Systemic antibiotics are not well absorbed into deep burns because of the lack of circulation.

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 rolled towel under the neck.

ANS: B

The right hand and arm should be elevated to reduce swelling and the fingers extended to avoid flexion contractures (even though this position may not be comfortable for the patient). The patient with burns of the ears should not use a pillow for the head because this will put pressure on the ears, and the pillow may stick to the ears. Patients with neck burns should not use a pillow because the head should be maintained in an extended position in order to avoid contractures.

A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take?

a. Notify the health care provider.

b. Monitor the pulses every 2 hours.

c. Elevate both legs above heart level with pillows.

d. Encourage the patient to flex and extend the toes on both feet.

ANS: A

The decrease in pulse in a patient with circumferential burns indicates decreased circulation to the legs and the need for an escharotomy. Monitoring the pulses is not an adequate response to the decrease in circulation. Elevating the legs or increasing toe movement will not improve the patient's circulation

Esomeprazole (Nexium) is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which nursing assessment would best evaluate the effectiveness of the medication?

a. Bowel sounds

b. Stool frequency

c. Abdominal distention

d. Stools for occult blood

ANS: D

H2 blockers and proton pump inhibitors are given to prevent Curling's ulcer in the patient who has suffered burn injuries. Proton pump inhibitors usually do not affect bowel sounds, stool frequency, or appetite

The nurse is reviewing the medication administration record (MAR) on a patient with partial-thickness burns. Which medication is best for the nurse to administer before scheduled wound debridement?

a. Ketorolac (Toradol)

b. Lorazepam (Ativan)

c. Gabapentin (Neurontin)

d. Hydromorphone (Dilaudid)

ANS: D

Opioid pain medications are the best choice for pain control. The other medications are used as adjuvants to enhance the effects of opioids.

A young adult 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 statement by the patient indicates that the problem is resolving?

a. "I'm glad the scars are only temporary."

b. "I will avoid using a pillow, so my neck will be OK."

c. "I bet my boyfriend won't even want to look at me anymore."

d. "Do you think dark beige makeup foundation would cover this scar on my cheek?"

ANS: D

The willingness to use strategies to enhance appearance is an indication that the disturbed body image is resolving. Expressing feelings about the scars indicates a willingness to discuss appearance, but not resolution of the problem. Because deep partial-thickness burns leave permanent scars, a statement that the scars are temporary indicates denial rather than resolution of the problem. Avoiding using a pillow will help prevent contractures, but it does not address the problem of disturbed body image

The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine output has dramatically increased. Which action by the nurse would best ensure adequate kidney function?

a. Continue to monitor the urine output.

b. Monitor for increased white blood cells (WBCs).

c. Assess that blisters and edema have subsided.

d. Prepare the patient for discharge from the burn unit.

ANS: A

The patient's urine output indicates that the patient is entering the acute phase of the burn injury and moving on from the emergent stage. At the end of the emergent phase, capillary permeability normalizes and the patient begins to diurese large amounts of urine with a low specific gravity. Although this may occur at about 48 hours, it may be longer in some patients. Blisters and edema begin to resolve, but this process requires more time. White blood cells may increase or decrease, based on the patient's immune status and any infectious processes. The WBC count does not indicate kidney function. The patient will likely remain in the burn unit during the acute stage of burn injury

A patient with burns covering 40% total body surface area (TBSA) is in the acute phase of burn treatment. Which snack would be best for the nurse to offer to this patient?

a. Bananas

b. Orange gelatin

c. Vanilla milkshake

d. Whole grain bagel

ANS: C

A patient with a burn injury needs high protein and calorie food intake, and the milkshake is the highest in these nutrients. The other choices are not as nutrient-dense as the milkshake. Gelatin is likely high in sugar. The bagel is a good carbohydrate choice, but low in protein. Bananas are a good source of potassium, but are not high in protein and calories.

A patient has just arrived in the emergency department after an electrical burn from exposure to a high-voltage current. What is the priority nursing assessment?

a. Oral temperature

b. Peripheral pulses

c. Extremity movement

d. Pupil reaction to light

ANS: C

All patients with electrical burns should be considered at risk for cervical spine injury, and assessments of extremity movement will provide baseline data. The other assessment data are also necessary but not as essential as determining the cervical spine status

An employee spills industrial acids on both arms and legs at work. What is the priority action that the occupational health nurse at the facility should take?

a. Remove nonadherent clothing and watch.

b. Apply an alkaline solution to the affected area.

c. Place cool compresses on the area of exposure.

d. Cover the affected area with dry, sterile dressings.

ANS: A

With chemical burns, the initial action is to remove the chemical from contact with the skin as quickly as possible. Remove nonadherent clothing, shoes, watches, jewelry, glasses, or contact lenses (if face was exposed). Flush chemical from wound and surrounding area with copious amounts of saline solution or water. Covering the affected area or placing cool compresses on the area will leave the chemical in contact with the skin. Application of an alkaline solution is not recommended.

A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 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.

ANS: D

Agitation in a patient who may have suffered inhalation injury might indicate hypoxia, and this should be assessed by the nurse first. Administration of morphine may be indicated if the nurse determines that the agitation is caused by pain. Assessing level of consciousness and orientation is also appropriate but not as essential as determining whether the patient is hypoxemic. Reassurance is not helpful to reduce agitation in a hypoxemic patient

A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first?

a. Auscultate the patient's lung sounds.

b. Determine the extent and depth of the burns.

c. Infuse the ordered lactated Ringer's solution.

d. Administer the ordered hydromorphone (Dilaudid).

ANS: A

A patient with facial and chest burns is at risk for inhalation injury, and assessment of airway and breathing is the priority. The other actions will be completed after airway management is assured.

A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first?

a. Assess oral temperature.

b. Check a potassium level.

c. Place on cardiac monitor.

d. Assess for pain at contact points.

ANS: C

After an electrical burn, the patient is at risk for fatal dysrhythmias and should be placed on a cardiac monitor. Assessing the oral temperature is not as important as assessing for cardiac dysrhythmias. Checking the potassium level is important. However, it will take time before the laboratory results are back. The first intervention is to place the patient on a cardiac monitor and assess for dysrhythmias, so that they can be treated if occurring. A decreased or increased potassium level will alert the nurse to the possibility of dysrhythmias. The cardiac monitor will alert the nurse immediately of any dysrhythmias. Assessing for pain is important, but the patient can endure pain until the cardiac monitor is attached. Cardiac dysrhythmias can be lethal.

Eight hours after a thermal burn covering 50% of a patient's total body surface area (TBSA) the nurse assesses the patient. Which information would be a priority to communicate to the health care provider?

a. Blood pressure is 95/48 per arterial line.

b. Serous exudate is leaking from the burns.

c. Cardiac monitor shows a pulse rate of 108.

d. Urine output is 20 mL per hour for the past 2 hours.

ANS: D

The urine output should be at least 0.5 to 1.0 mL/kg/hr during the emergent phase, when the patient is at great risk for hypovolemic shock. The nurse should notify the health care provider because a higher IV fluid rate is needed. BP during the emergent phase should be greater than 90 systolic, and the pulse rate should be less than 120. Serous exudate from the burns is expected during the emergent phase

Which patient should the nurse assess first?

a. A patient with smoke inhalation who has wheezes and altered mental status

b. A patient with full-thickness leg burns who has a dressing change scheduled

c. A patient with abdominal burns who is complaining of level 8 (0 to 10 scale) pain

d. A patient with 40% total body surface area (TBSA) burns who is receiving IV fluids at 500 mL/hour

ANS: A

This patient has evidence of lower airway injury and hypoxemia and should be assessed immediately to determine the need for oxygen or intubation. The other patients should also be assessed as rapidly as possible, but they do not have evidence of life-threatening complications.

Which patient is most appropriate for the burn unit charge nurse to assign to a registered nurse (RN) who has floated from the hospital medical unit?

a. A 34-year-old patient who has a weight loss of 15% from admission and requires enteral feedings.

b. A 67-year-old patient who has blebs under an autograft on the thigh and has an order for bleb aspiration

c. A 46-year-old patient who has just come back to the unit after having a cultured epithelial autograft to the chest

d. A 65-year-old patient who has twice-daily burn debridements and dressing changes to partial-thickness facial burns

ANS: A

An RN from a medical unit would be familiar with malnutrition and with administration and evaluation of response to enteral feedings. The other patients require burn assessment and care that is more appropriate for staff who regularly care for burned patients.

A patient who was found unconscious in a burning house is brought to the emergency department by ambulance. The nurse notes that the patient's skin color is bright red. Which action should the nurse take first?

a. Insert two large-bore IV lines.

b. Check the patient's orientation.

c. Assess for singed nasal hair and dark oral mucous membranes.

d. Place the patient on 100% oxygen using a non-rebreather mask.

ANS: D

The patient's history and skin color suggest carbon monoxide poisoning, which should be treated by rapidly starting oxygen at 100%. The other actions can be taken after the action to correct gas exchange.

The nurse is reviewing laboratory results on a patient who had a large burn 48 hours ago. Which result requires priority action by the nurse?

a. Hematocrit 53%

b. Serum sodium 147 mEq/L

c. Serum potassium 6.1 mEq/L

d. Blood urea nitrogen 37 mg/dL

ANS: C

Hyperkalemia can lead to fatal dysrhythmias and indicates that the patient requires cardiac monitoring and immediate treatment to lower the potassium level. The other laboratory values are also abnormal and require changes in treatment, but they are not as immediately life threatening as the elevated potassium level

The charge nurse observes the following actions being taken by a new nurse on the burn unit. Which action by the new nurse would require an intervention by the charge nurse?

a. The new nurse uses clean latex gloves when applying antibacterial cream to a burn wound.

b. The new nurse obtains burn cultures when the patient has a temperature of 95.2° F (35.1° C).

c. The new nurse administers PRN fentanyl (Sublimaze) IV to a patient 5 minutes before a dressing change.

d. The new nurse calls the health care provider for a possible insulin order when a nondiabetic patient's serum glucose is elevated.

ANS: A

Sterile gloves should be worn when applying medications or dressings to a burn. Hypothermia is an indicator of possible sepsis, and cultures are appropriate. Nondiabetic patients may require insulin because stress and high calorie intake may lead to temporary hyperglycemia. Fentanyl peaks 5 minutes after IV administration, and should be used just before and during dressing changes for pain management

Which nursing action is a priority 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.

ANS: B

Cervical spine injuries are commonly associated with electrical burns. Therefore stabilization of the cervical spine takes precedence after airway management. The other actions are also included in the emergent care after electrical burns, but the most important action is to avoid spinal cord injury.

Which action will the nurse include in the plan of care for a patient in the rehabilitation phase after a burn injury to the right arm and chest?

a. Keep the right arm in a position of comfort.

b. Avoid the use of sustained-release narcotics.

c. Teach about the purpose of tetanus immunization.

d. Apply water-based cream to burned areas frequently.

ANS: D

Application of water-based emollients will moisturize new skin and decrease flakiness and itching. To avoid contractures, the joints of the right arm should be positioned in an extended position, which is not the position of comfort. Patients may need to continue the use of opioids during rehabilitation. Tetanus immunization would have been given during the emergent phase of the burn injury

A young adult patient who is in the rehabilitation phase 6 months after a severe face and neck burn tells the nurse, "I'm sorry that I'm still alive. My life will never be normal again." Which response by the nurse is best?

a. "Most people recover after a burn and feel satisfied with their lives."

b. "It's true that your life may be different. What concerns you the most?"

c. "It is really too early to know how much your life will be changed by the burn."

d. "Why do you feel that way? You will be able to adapt as your recovery progresses."

ANS: B

This response acknowledges the patient's feelings and asks for more assessment data that will help in developing an appropriate plan of care to assist the patient with the emotional response to the burn injury. The other statements are accurate, but do not acknowledge the anxiety and depression that the patient is expressing.

In which order will the nurse take these actions when doing a dressing change for a partial-thickness burn wound on a patient's chest? (Put a comma and a space between each answer choice [A, B, C, D, E].)

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

ANS:

D, E, C, A, B

Because partial-thickness burns are very painful, the nurse's first action should be to administer pain medications. The wound will then be cleaned, antibacterial cream applied, and covered with a new sterile dressing. The last action should be to document the appearance of the wound.

An 80-kg patient with burns over 30% of total body surface area (TBSA) is admitted to the burn unit. Using the Parkland formula of 4 mL/kg/%TBSA, what is the IV infusion rate (mL/hour) for lactated Ringer's solution that the nurse will administer during the first 8 hours?

600 mL

The Parkland formula states that patients should receive 4 mL/kg/%TBSA burned during the first 24 hours. Half of the total volume is given in the first 8 hours and then the last half is given over 16 hours: 4 80 30 = 9600 mL total volume; 9600/2 = 4800 mL in the first 8 hours; 4800 mL/8 hr = 600 mL/hr.

A patient comes into the emergency department with a chemical burn from contact with lye.Assessment and treatment of this patient will be based on what knowledge regarding this type of burn? (Select all that apply)

1. This is an alkali burn.

2. This type of burn tends to be deeper.

3. This is an acid burn.

4. This type of burn will be easier to neutralize.

5. This type of burn tends to be more superficial.

Correct Answer: 1,2

Rationale: This is an alkali burn which is more difficult to neutralize than an acid burn and tends to have a deeper penetration and be more severe than a burn caused by an acid.

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 degrees F

b. Use only hardwired smoke detectors

c. Encourage regular home fire exit drills

d. Never permit older adults to cook unattended

1. Correct answer: c

Rationale: A risk-reduction strategy for household fires is to encourage regular home fire exit drills. 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). 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. Supervision of older adults who are cooking is necessary only if cognitive alterations are observed.

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?

A. The total 24-hour fluid requirement should be administered in the first 8 hours.

B. One half of the total 24-hour fluid requirement should be administered in the first 8 hours.

C. One third of the total 24-hour fluid requirement should be administered in the first 4 hours.

D. One half of the total 24-hour fluid requirement should be administered in the first 4 hours.

B. One half of the total 24-hour fluid requirement should be administered in the first 8 hours.

Fluid resuscitation with the Parkland (Baxter) formula recommends that one half of the total fluid requirement should be administered in the first 8 hours, one quarter of total fluid requirement should be administered in the second 8 hours, and one quarter of total fluid requirement should be administered in the third 8 hours.

A patient arrives at the emergency department with an electrical burn. What assessment questions should the nurse ask in determining the possible severity of the burn injury? Select all that apply.

1. What type of current was involved?

2. How long was the patient in contact with the current?

3. How much voltage was involved?

4. Where was the patient when the burn occurred?

5. What was the point of contact with the current?

Correct Answer: 1,2,3

Rationale: The severity of electrical burns depends on the type and duration of the current and amount of voltage. Location is not important in determining possible severity. Location is not important in determining possible severity.

The nurse is caring for a patient with superficial partial-thickness burns of the face sustained within the last 12 hours. Upon assessment the nurse would expect to find which manifestation?

A. Blisters

B. Reddening of the skin

C. Destruction of all skin layers

D. Damage to sebaceous glands

B. Reddening of the skin

The clinical appearance of superficial partial-thickness burns includes erythema, blanching with pressure, and pain and minimal swelling with no vesicles or blistering during the first 24 hours.

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

Correct answer: a

Rationale: Full-thickness burns may be caused by contact with flames, scalding liquids, chemicals, tar, or electrical current.

A nurse sees a patient get struck by lightning during a thunder storm on a golf course. What should be the FIRST action by the nurse?

1. Check breathing and circulation.

2. Look for entrance and exit wounds.

3. Cover the patient to prevent heat loss.

4. Move the patient indoors to a dry place.

5. Get the patient up off the ground.

Correct Answer: 1

Rationale: Cardiopulmonary arrest is the most common cause of death from lightening. Respiratory and cardiac status should be assessed immediately to determine if CPR is necessary. All other actions are secondary.

The nurse is planning care for a patient with partial- and full-thickness skin destruction related to burn injury of the lower extremities. Which interventions should the nurse expect to include in this patient's care? (Select all that apply.)

A. Escharotomy

B. Administration of diuretics

C. IV and oral pain medications

D. Daily cleansing and debridement

E. Application of topical antimicrobial agent

A, C, D, E.

An escharotomy (a scalpel incision through full-thickness eschar) is frequently required to restore circulation to compromised extremities. Daily cleansing and debridement as well as application of an antimicrobial ointment are expected interventions used to minimize infection and enhance wound healing. Pain control is essential in the care of a patient with a burn injury. With full-thickness burns, myoglobin and hemoglobin released into the bloodstream can occlude renal tubules. Adequate fluid replacement is used to prevent this occlusion.

When assessing a patient with a partial-thickness burn, the nurse would expect to find (SATA):

a. blisters

b. exposed fascia

c. exposed muscles

d. intact nerve endings

e. red, shiny, wet appearance

Correct answers: a, d, e

Rationale: The appearance of partial-thickness (deep) burns may include fluid-filled vesicles (blisters) that are red, shiny, or wet (if vesicles have ruptured). Patients may have severe pain caused by exposure of nerve endings and may have mild to moderate edema.

A patient is admitted to the burn center with burns of his head and neck, chest, and back 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. obtain vital signs and a STAT ABG

b. encourage the patient to cough and auscultate the lungs again

c. document the findings and continue to monitor the patient's breathing

d. anticipate the need for endotracheal intubation and notify the physician

Correct answer: d

Rationale: Inhalation injury results in 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 intubation and mechanical ventilation because this patient is demonstrating signs of severe respiratory distress.