Burns Ch.62 with Explanations

Which of the following provides clues about fluid volume status? Select all that apply.

Hourly urine output

• Daily weights

Explanation:

Monitoring of hourly urine output and daily weights provides clues about fluid volume status. Percentage of meals eaten, skin turgor, and oxygen saturation would not be reliable indicators of fluid volume status in the burn injured patient.

Acticoat antimicrobial barrier dressings used in the treatment of burn wounds can be left in place for which timeframe?

5 days

The nurse is caring for a patient with superficial partial-thickness burn injuries to the lower extremities. The patient is ordered IV morphine for pain. The nurse understands narcotics are given IV to manage pain during the initial management of pain because of which of the following?

a) Tissue edema may interfere with drug absorption via other routes.

b) The patient can experience nausea and emesis when given oral medications.

c) Bleeding may occur at injection sites when the intramuscular route is used.

d) Pain resulting from a burn injury requires relief by the fastest route available.

Tissue edema may interfere with drug absorption via other routes.

Explanation:

IV administration is necessary because of altered tissue perfusion from the burn injury.

A patient has been prescribed mafenide acetate (Sulfamylon) cream for burn treatment. The nurse should educate the patient regarding which of the following?

a) Stains clothing

b) Severe burning pain for up to 20 minutes

c) Blood levels of sodium and potassium will be monitored.

d) Can be left in place for 3 to 5 days

Severe burning pain for up to 20 minutes

Explanation:

The patient should be premedicated with analgesic before applying mafenide acetate because this agent causes severe burning pain for up to 20 minutes after application. Silver nitrate stains everything it touches black. Acticoat dressings can be left in place for 3 to 5 days. Silver nitrate solution acts as a wick for sodium and potassium; serum levels of these electrolytes need to be monitored

A patient has undergone grafting following a burn injury. The nurse understands that the first dressing change at the site of an autograft is performed how soon after the surgery?

a) Within 12 hours after surgery

b) As soon as sanguineous drainage is noted

c) 2 to 5 days after surgery

d) Within 24 hours after surgery

2 to 5 days after surgery

Explanation:

The first dressing change usually occurs 2 to 5 days after surgery. In addition, a foul odor or purulence may indicate infection and should be reported to the surgeon immediately. Sanguineous drainage on a dressing covering an autograft is an anticipated abnormal observation postoperatively.

A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following?

a) Superficial partial-thickness

b) Superficial

c) Full-thickness

d) Deep partial-thickness

Full-thickness

Correct

Explanation:

A full-thickness burn involves total destruction of the dermis and extends into the subcutaneous fat. It can also involve muscle and bone. A superficial burn only damages the epidermis. In a superficial partial-thickness burn, the epidermis is destroyed and a small portion of the underlying dermis is injured. A deep partial-thickness burn extends into the reticular layer of the dermis and is hard to distinguish froma full-thickness burn. It is red or white, mottled, and can be moist or fairly dry

Which type of debridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar?

a) Chemical debridement

b) Mechanical debridement

c) Natural debridement

d) Surgical debridement

Mechanical debridement

Explanation:

Mechanical debridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar. Topical enzymatic debridement agents are available to promote debridement of the burn wounds. With natural debridement, the dead tissue separates from the underlying viable tissue spontaneously. Surgical debridement is an operative procedure involving either primary excision (surgical removal of tissue) of the full thickness of the skin down to the fascia (tangential excision) or shaving of the burned skin layers gradually down to freely bleeding, viable tiss

A patient is brought to the ED by a coworker following a burn injury from a high-voltage electrical power line. The triage nurse will complete which of the following interventions first?

a) Take the patient's vital signs.

b) Obtain a 12-lead ECG.

c) Insert a urinary Foley catheter.

d) Apply a cervical collar on the patient.

Apply a cervical collar on the patient.

Correct

Explanation:

Until it is known that the patient has no fractures, it is imperative that a neck collar be applied and remain in place and that the patient is log rolled to eliminate the chance of further spinal cord injury. With high-voltage electrical injuries, cervical spine immobilization is a priority until cervical spine injury is ruled out. The other interventions may be completed; however, the priority intervention is to apply the collar.

The nurse understands that during the emergent/resuscitative phase of burn injury, hemoconcentration is due to which of the following?

a) Liquid blood component is lost into extravascular space

b) Fluid loss

c) Decreased renal blood flow

d) Sodium and water retention caused by increase adrenocortical activity

You selected: Liquid blood component is lost into extravascular space

Correct

Explanation:

Hemoconcentration is due to the blood component being lost into the extravascular space. Decreased urinary output occurs secondary to fluid loss, decreased renal blood flow, and sodium and water retention caused by increased adrenocortical activity.

When the emergency nurse learns that the patient suffered injury from a flash flame, the nurse anticipates which depth of burn?

a) Full thickness

b) Deep partial thickness

c) Superficial partial thickness

d) Superficial

Deep partial thickness

Explanation:

A deep partial thickness burn is similar to a second-degree burn and is associated with scalds and flash flames. Superficial partial thickness burns are similar to first-degree burns and are associated with sunburns. Full thickness burns are similar to third-degree burns and are associated with direct flame, electric current, and chemical contact. Injury from a flash flame is not associated with a burn that is limited to the epidermis.

When using the Palmar method to estimate the extent of a small or scattered burn injury, the palm is equal to which percentage of total body surface area (TBSA)?

a) 2

b) 4

c) 1

d) 3

1

Correct

Explanation:

In patients with scattered burns, or for a quick prehospital assessment, the Palmer method may be used to estimate the extent of the burns. The size of the patient's palm, not including the surface area of the digits, is approximately 1% of the TBSA.

A patient is being cared for in a burn unit after suffering partial-thickness burns. The patient's laboratory work reveals a positive wound culture for gram-negative bacteria. The health care provider orders silver sulfadiazine (Silvadene) to be applied to the patient's burns. The nurse provides information to the patient about the medication. Which of the following statements made by the patient indicates an understanding about this treatment? Select all that apply.

a) "This medication is an antibacterial."

b) "This medication will stain my skin permanently."

c) "This medication will help my burn heal."

d) "This medication will be applied directly to the wound."

"This medication is an antibacterial."

• "This medication will help my burn heal."

• "This medication will be applied directly to the wound."

Correct

Explanation:

This medication is an antibacterial, which has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. This medication is directly applied to the wound. This medication will not stain the patient's skin, but it will help heal the patient's burned areas.

Which of the following are possible indicators of pulmonary damage from an inhalation injury? Select all that apply.

a) Facial burns

b) Yellow sputum

c) Hoarseness

d) Singed nasal hair

e) Bradypnea

• Singed nasal hair

• Hoarseness

• Facial burns

Explanation:

Indicators of possible pulmonary damage include singed nasal hair, hoarseness, voice change, stridor, burns of the face or neck, sooty or bloody sputum, and tachypnea.

Which of the following is the analgesic of choice for burn pain?

a) Fentanyl

b) Demerol

c) Tylenol with codeine

d) Morphine sulfate

Morphine sulfate remains the analgesic of choice. It is titrated to obtain pain relief on the patient's self-report of pain. Fentanyl is particularly useful for procedural pain, because it has a rapid onset, high potency, and short duration, all of which make it effective for use with procedures. Demerol and Tylenol with codeine are not analgesics of choice for burn pain.

Which of the following is to be expected soon after a major burn? Select all that apply.

a) Bradycardia

b) Anxiety

c) Hypertension

d) Hypotension

e) Tachycardia

• Anxiety

• Hypotension

• Tachycardia

Correct

Explanation:

Tachycardia, slight hypotension, and anxiety are expected soon after the burn.

Several temporary and permanent sources are available for covering a burn wound. These may be manufactured synthetically, obtained from a biologic source, or a combination of the two. Select the graft described as the following: a biologic source of skin similar to that of the client.

a) Autograft

b) Allograft

c) Xenograft

d) Slit graft

Allograft

Explanation:

Allograft or homograft is a biologic source of skin similar to that of the client. A xenograft or heterograft is obtained from animals, principally pigs or cows. An autograft uses the client's own skin, transplanted from one part of the body to another. A slit graft is a type of autograft.

The most important intervention in the nutritional support of a patient with a burn injury is to provide adequate nutrition and calories to promote which of the following?

a) Increased metabolic rate

b) Increased skeletal muscle breakdown

c) Decreased catabolism

d) Increased glucose demands

Decreased catabolism

Correct

Explanation:

Burn injuries produce profound metabolic abnormalities fueled by the exaggerated stress response to the injury. The body's response has been classified as hyperdynamic, hypermetabolic, and hypercatabolic. The most important intervention in the nutritional support of a patient with a burn injury is to provide adequate nutrition and calories to decrease catabolism. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50%. A marked increase in metabolic rate is seen after a burn injury and interventions are instituted to decrease metabolic rate and catabolism. A marked increase in glucose demand is seen after a burn injury and interventions are instituted to decrease glucose demands and catabolism. Rapid skeletal muscle breakdown with amino acids serving as the energy source is seen after a burn injury and interventions are instituted to decrease catabolism.

Determining the depth of a burn is difficult initially because there are combinations of injury zones in the same location. The following describes one of the injury zones: the area of intermediate burn injury. It is here that blood vessels are damaged, but tissue has the potential to survive. What is the name of that zone?

a) Zone of stasis

b) Zone of coagulation

c) Zone of hyperemia

d) Zone of hypotension

Zone of stasis

Explanation:

The zone of stasis is the area of intermediate burn injury. It is here that blood vessels are damaged, but tissue has the potential to survive. The zone of coagulation is at the center of the injury, and it is the area where the injury is most severe and usually deepest. The zone of hyperemia is the area of least injury, where the epidermis and dermis are only minimally damaged. This is not the name of one of the zones.

The nurse is caring for a patient in the burn unit. Which of the following may be an early sign of sepsis in the patient with burn injury?

a) Clammy skin

b) Decreased pulse rate

c) Hyperthermia

d) Narrowing pulse pressure

Narrowing pulse pressure

Explanation:

Patients with burns are hypermetabolic. This results in tachycardia, tachypnea, and elevated body temperature. These physiological norms in patients with burns make the diagnosis of sepsis more challenging. The signs of early systemic sepsis are subtle and require a high index of suspicion and very close monitoring of changes in the patient's status. Early signs of sepsis may include increased temperature, increased pulse rate, widened pulse pressure, and flushed dry skin in unburned areas.

Bill Jenkins has suffered from a burn on his leg related to an engine fire. Burn depth is determined by assessing the color, characteristics of the skin, and sensation in the area. When the burn area was assessed, it was determined that he felt no pain in the area and that it appeared charred. What depth of burn injury would he be said to have?

a) Fourth degree

b) Superficial (first degree)

c) Full thickness (third degree)

d) Superficial partial-thickness and deep partial-thickness (second degree)

Full thickness (third degree)

Explanation:

Full-thickness (third degree) burn destroys all layers of the skin and consequently is painless. The tissue appears charred or lifeless. Superficial (first degree) burn is similar to a sunburn. The epidermis is injured, but the dermis is unaffected. Superficial partial-thickness burn heals within 14 days, with possibly some pigmentary changes but no scarring. The deep partial-thickness (second degree) burn takes more than 3 weeks to heal, may need debridement, and is subject to hypertrophic scarring. A fourth-degree burn can involve ligaments, tendons, muscles, nerves, and bone.

All of the following are antimicrobials commonly used to treat burns except:

a) Tetracycline

b) Silver sulfadiazine (Silvadene)

c) Mafenide (Sulfamylon)

d) Silver nitrate (AgNO3) 0.5% solution

Tetracycline

Correct

Explanation:

Silver sulfadiazine (Silvadene), mafenide (Sulfamylon), and silver nitrate (AgNO3) 0.5% solution are the three major antimicrobials used to treat burns.

Which of the following is the preferred IV fluid for burn resuscitation?

a) Lactated Ringer's (LR)

b) D5W

c) Total parenteral nutrition (TPN)

d) Normal saline (NS)

Lactated Ringer's (LR)

Correct

Explanation:

LR is the preferred IV fluid for burn resuscitation because the sodium concentration and potassium are similar to normal intravascular levels. NS, D5W, and TPN are not the IV of choice for burn resuscitation.

Which of the following is the key sign of onset of ARDS?

a) Tachypnea

b) Stridor

c) Hypoxemia

d) Chest pain

hypoxemia

Explanation:

The key sign of the onset of ARDS is hypoxemia while receiving 100% oxygen, with decreased lung compliance and significant shunting. The physician should be notified immediately of deteriorating respiratory status.

Which of the following topical burn preparations act as wick for sodium and potassium?

a) Silver nitrate solution

b) Silver sulfadiazine (Silvadene)

c) Mafenide acetate (Sulfamylon)

d) Acticoat

Silver nitrate solution

Correct

Explanation:

Silver nitrate solution is hypotonic and acts as a wick for sodium and potassium. The other preparations do not act as a wick for sodium and potassium.

A 42-year-old client suffered significant burns in a workplace accident. During his airlift to a regional burn unit, you assess his wounds taking care to find and mark his entrance and exit wounds. Which of the following conditions create the need for intensive care by specifically trained personnel?

a) Fluid shift

b) Fluid loss

c) All options are correct.

d) Hypotension

• All options are correct.

• Fluid shift

• Fluid loss

• Hypotension

Explanation:

Fluid shift, fluid loss, and hypotension can lead to irreversible shock. These changes usually happen rapidly and the client's status may change from hour to hour, requiring that clients with burns receive intensive care by skilled personnel.

Tom Benson, a 42-year-old electrical lineman, suffered significant burns in a workplace accident. During his airlift to a regional burn unit, you assess his wounds taking care to find and mark his entrance and exit wounds. What occurrence makes it difficult to assess internal burn damage in electrical burns?

a) Protein cell coagulation

b) All options are correct.

c) Continuing inflammatory process

d) Deep tissue cooling

Deep tissue cooling

Explanation:

Because deep tissues cool more slowly than those at the surface, it is difficult initially to determine the extent of internal damage.

The nurse is caring for a 30-year-old female patient who suffered severe head and facial burn injuries. Which of the following actions, if completed by the patient, indicates she is adapting to her altered body image? Select all that apply.

a) Reports absence of sleep disturbance

b) Wears hats and wigs

c) Covers her face with a scarf

d) Participates actively in daily activities

• Wears hats and wigs

• Participates actively in daily activities

Correct

Explanation:

The following are indicators that a patient is adapting to altered body image: verbalizes accurate description of alterations in body image and accepts physical appearance, demonstrates interest in resources that may improve function and perception of body appearance (e.g., uses cosmetics, wigs, and prostheses, as appropriate); socializes with significant others, peers, and usual social group; and seeks and achieves return to role in family, school, and community as a contributing member. Covering the face with a scarf indicates the patient is not adapting to the alteration in body image; absence of sleep disturbances is expected by the burn-injured patient but is not related to body image disturbance.

When using the palmar method to estimate the extent of the burn injury, the palm is equal to which percentage of TBSA?

a) 3

b) .5

c) 4

d) 2

.5

Explanation:

In patients with scattered burns, or for a quick prehospital assessment, the palmer method may be used to estimate the extent of the burns. The size of the patient's palm, not including the surface area of the digits, is approximately 0.5% of the TBSA

Following a burn injury, which of the following areas is the priority for nursing assessment?

a) Pulmonary system

b) Cardiovascular system

c) Nutrition

d) Pain

Airway patency and breathing must be assessed during the initial minutes of emergency care. Immediate therapy is directed toward establishing an airway and administering humidified 100% oxygen. Pulmonary problems may be caused by the inhalation of heat and/or smoke or edema of the airway. Assessing a patent airway is always a priority after a burn injury followed by breathing. Remember the ABCs.

Which of the following measures can be used to cool a burn?

a) Using cold soaks or dressings for at least 1 hour

b) Application of cool water

c) Wrapping the person in ice

d) Application of ice directly to burn

Application of cool water

Explanation:

Once a burn has been sustained, the application of cool water is the best first-aid measure. 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.

Which of the following actions is a quick assessment technique that the nurse might use to assess the percentage of a small or scattered burn injury?

a) Checking the patient's vital signs

b) Comparing the patient's palm with the size of the burn wound

c) Observing the patient's level of consciousness

d) Observing the color of the patient's wound

b

Which of the following complications is common for victims of electrical burns?

a) Inhalation injury

b) Infection

c) Hypovolemic shock

d) Cardiac dysrhythmia

Cardiac dysrhythmia

Correct

Explanation:

Cardiac dysrhythmias are common for victims of electrical burns. If the patient has an electrical burn, a baseline electrocardiogram (ECG) is obtained and continuous monitoring is initiated. Any burn injury can lead to complications, such as inhalation injury, infection, and hypovolemic shock.

Molly Baker has a third-degree burn on her leg from a house fire. The wound is being treated by the open method. After about 4 days, a hard crust has formed around the leg and is impairing the circulation to her leg. What procedure would be done to relieve pressure on the affected area?

a) Allograft

b) Escharotomy

c) Silvadene application

d) Debridement

Escharotomy

Correct

Explanation:

Debridement is the removal of necrotic tissue. An escharotomy is an incision into the eschar to relieve pressure on the affected area. An allograft would not be the treatment. Silvadene may be part of the treatment regimen but not specifically for this situation.

Within the practice of nursing at the burn unit, there are specific potential complications common to specific types of burns. Which burns can impair ventilation?

a) Face, neck, chest

b) Perineal

c) All options are correct.

d) Hands, major joints

Face, neck, chest

Correct

Explanation:

Burns of the face, neck, or chest have the potential to impair ventilation.

A patient with a burn wound is prescribed mafenide acetate 5% (Sulfamylon) twice daily. Nursing implications associated with this medication include which of the following?

a) Premedicating the patient with an analgesic prior to application

b) Monitoring the patient's Na+ and K+ serum levels and replace as prescribed

c) Monitoring the patient for the development of respiratory acidosis

d) Protecting the bed linens and patient's clothing from contact to prevent staining

Premedicating the patient with an analgesic prior to application

Correct

Explanation:

Mafenide is a strong carbonic anhydrase inhibitor and may cause metabolic acidosis. Application may cause considerable pain initially, thus premedicating the patient is an appropriate intervention. The other nursing implications are not associated with mafenide.

The nurse is providing care for a patent with a full-thickness, circumferential burn of the left lower leg. During the nurse's initial shift assessment, the patient is resting and the physical assessment of the left lower extremity is unremarkable. One hour later, the nurse notes the pulses of the left lower leg cannot be obtained by a Doppler ultrasound device, and the capillary refill of the left great toe is greater than 2 seconds. The nurse's best response based on the clinical findings is which of the following?

a) Apply an elastic stocking to the extremity and administer SQ heparin per order.

b) Document the findings and instruct the patient to report numbness of the extremity.

c) Contact the primary care provider and prepare for an escharotomy.

d) Elevate the leg on pillows and reassess the leg in 1 hour.

You selected: Contact the primary care provider and prepare for an escharotomy.

Correct

Explanation:

The nurse assesses peripheral pulses frequently with a Doppler ultrasound device, if needed. Frequent assessment also includes warmth, capillary refill, sensation, and movement of extremity. It is necessary for the nurse to report loss of pulse or sensation or presence of pain to the physician immediately and to prepare to assist with an escharotomy. The other interventions are inappropriate when the nurse has detected a loss of peripheral pulses.

A patient has been prescribed Acticoat as a burn wound treatment. Which of the following is accurate regarding application of Acticoat?

a) Moisten with sterile water only.

b) Moisten with saline.

c) Keep Acticoat saturated.

d) Use topical antimicrobials with Acticoat burn dressing.

Moisten with sterile water only.

Explanation:

Acticoat is moistened with sterile water only; never use normal saline. Do not use topical antimicrobials with Acticoat burn dressing. Keep Acticoat moist, not saturated.

At the scene of a fire, the first priority is to prevent further injury. What are interventions at the site that can help to prevent injury? Choose all that apply.

a) Open door and encourage air in an enclosed space.

b) Place the client in a horizontal position.

c) Place the client in a vertical position.

d) Roll the client in a blanket to smother the fire.

• Place the client in a horizontal position.

• Roll the client in a blanket to smother the fire.

Explanation:

If the clothing is on fire, the client is placed in a horizontal position and rolled in a blanket to smother the fire.

Which of the following fluid or electrolyte changes occur in the emergent/resuscitative phase?

a) Reduction in blood volume

b) Sodium excess

c) Increased urinary output

d) Potassium deficit

Reduction in blood volume

Correct

Explanation:

A reduction in blood volume occurs secondary to plasma loss. Sodium deficit, potassium excess, and decreased urinary output occurs in this phase.

Which type of burn injury involves destruction of the epidermis and upper layers of the dermis and injury to the deeper portions of the dermis?

a) Fourth degree

b) Full-thickness

c) Deep partial-thickness

d) Superficial partial-thickness

Deep partial-thickness

Correct

Explanation:

A deep partial-thickness burn involves destruction of the epidermis and upper layers of the dermis and injury to deeper portions of the dermis. In a superficial partial-thickness burn, the epidermis is destroyed or injured and a portion of the dermis may be injured. Capillary refill follows tissue blanching. Hair follicles remain intact. A full-thickness burn involves total destruction of epidermis and dermis and, in some cases, destruction of underlying tissue, muscle, and bone. Although the term fourth-degree burn is not used universally, it occurs with prolonged flame contact or high voltage injury that destroys all layers of the skin and damages tendons and muscles.

A patient presents to the ED following a burn injury. The patient has burns to the anterior chest and entire left leg. Using the rule of nines, the nurse documents the total body surface area (TBSA) percentage as which of the following?

a) 9%

b) 36%

c) 18%

d) 27%

36% (questionable)

Explanation:

The rule-of-nines system is based on dividing anatomic regions, each representing approximately 9% of the TBSA, quickly allowing clinicians to obtain an estimate. If a portion of an anatomic area is burned, the TBSA is calculated accordingly—for example, if approximately half of the anterior leg is burned, the TBSA burned would be 4.5%. More specifically, with an adult who has been burned, the percent of the body involved can be calculated as follows: head = 9%, chest (front) = 9%, abdomen (front) = 9%, upper/mid/low back and buttocks = 18%, each arm = 9% (front = 4.5%, back = 4.5%), groin = 1%, and each leg = 18% total (front = 9%, back = 9%).

The nurse is caring for a patient with extensive burn injuries. Which of the following parameters would the nurse evaluate to determine if the patient is receiving adequate fluid resuscitation? Select all that apply.

a) Heart rate

b) Urine output

c) Oxygen saturation

d) Blood pressure

• Blood pressure

• Heart rate

• Urine output

Explanation:

Fluid resuscitation is administered to maintain adequate cardiac output and tissue perfusion. If adequate fluid is administered, tachycardia, hypotension, and oliguria will resolve. Expected outcomes of fluid resuscitation specifically include the following: urine output between 0.5 and 1.0 mL/kg/hr (30-50 mL/hr; 75 to 100 mL/hr if electrical burn injury), mean arterial pressure (MAP) pressure > 60 mm Hg, voids clear yellow urine with specific gravity within normal limits, and serum electrolytes are within normal limits

Which of the following is a potential cause of a superficial partial-thickness burn?

a) Scald

b) Flash flame

c) Sunburn

d) Electrical current

Sunburn

Correct

Explanation:

A potential cause of a superficial partial-thickness burn is a sunburn or low-intensity flash. Causes of deep partial-thickness burns are scalds and flash flames. Full-thickness burns may be caused by an electrical current or prolonged exposure to hot liquids.

A patient with a severe electrical burn injury is being treated in the burn unit. Which of the following laboratory results would cause the nurse the most concern?

a) K+: 5.0 mEq/L

b) BUN: 28 mg/dL

c) Na+: 145 mEq/L

d) Ca: 9 mg/dL

BUN: 28 mg/dL

Correct

Explanation:

The elevated BUN would case the nurse the most concern. The nurse should report decreased urine output or increased BUN and creatinine values to the physician. These laboratory values indicate possible renal failure. In addition, myoglobinuria, which is associated with electrical burns, is common with muscle damage and may also cause kidney failure if not treated. The other values are within normal limits.

A 6-year-old girl was playing near her family's campfire when she fell into the fire, suffering significant burns. She was taken by air ambulance to the burn unit where you practice nursing. What physiologic process furthers her burn injury?

a) Inflammatory

b) Intravascular fluid excess

c) Neuroendocrine

d) Hypertension

Inflammatory

Correct

Explanation:

The initial burn injury is further extended by inflammatory processes that affect layers of tissue below the initial surface injury.

A patient is being discharged after sustaining a deep-partial thickness burn during a house fire. The patient is asking when the burn will be healed. The nurse understands that this type of burn injury heals within which of the following time frames?

a) 8 weeks

b) 1 week

c) 6 weeks

d) 2 to 4 weeks

2 to 4 weeks

Correct

Explanation:

For deep partial-thickness burn injuries, recovery is expected in 2 to 4 weeks.

The nurse has completed teaching home care instructions to a patient being discharged from the burn unit. Which of the following patient statements indicates the need for further teaching?

"As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help."

Explanation:

Itching is a normal part of healing. Many clients describe this as one of the most uncomfortable aspects of burn recovery. The client can apply mild moisturizers to decrease itching from dryness. Medications can be discussed with your treatment team. The client should pat the areas; scratching is contraindicated. The other statements indicate that teaching has been effective.

A nurse is required to monitor the effectiveness of fluid resuscitation in a client who is being treated for burns. Which of the following assessments would indicate the success of the fluid resuscitation?

The client's urinary output is 0.3 to 0.5 mL/kg/hour.

Explanation:

Successful fluid resuscitation is gauged by a urinary output of 0.3 to 0.5 mL/kg/hour via an indwelling catheter. Fluid resuscitation does not directly affect the client's heart rate, breathing, or mental status

Which of the following is true regarding a split-thickness skin graft?

The epidermis and a thin layer of dermis are harvested from the client's skin.

Explanation:

In a split-thickness skin graft, the epidermis and a thin layer of the dermis are harvested from the client's skin. Their cosmetic appearance is less desirable. Hair does not grow back from their surface. Split thickness grafts are more successful that other types of grafts.

Which of the following is the effect of protein catabolism in a client with severe burns?

It compromises wound healing and immunocompetence.

Explanation:

Protein catabolism in a client with severe burns compromises wound healing and immunocompetence. Burns of the face, neck, or chest have the potential to impair ventilation, while burns involving the hands or major joints may affect dexterity and mobility. Release of aldosterone, not protein catabolism, causes sodium retention.

The nurse participates in a health fair about fire safety. When clothes catch fire, which intervention helps to minimize the risk of further injury to an affected person at a scene of a fire?

Roll the client in a blanket.

Explanation:

When clothing catches fire, the flames can be extinguished if the person drops to the floor or ground and rolls ("stop, drop, and roll"); anything available to smother the flames, such as a blanket, rug, or coat, may be used. The older adult, or others with impaired mobility, could be instructed to "stop, sit, and pat" to prevent concomitant musculoskeletal injuries. The client should not be covered immediately with a wet cloth or kept in any position other than horizontal. However, IV fluid therapy should be administered en route to the hospital.

A client who has been burned significantly is taken by air ambulance to the burn unit. What physiologic process furthers a burn injury?

inflammatory

Explanation:

The initial burn injury is further extended by inflammatory processes that affect layers of tissue below the initial surface injury.

A nurse is preparing a care plan for a client burned over 36% of his body 2 days ago. Which clinical manifestation indicates that the client has progressed into the intermediate phase of burn care?

The client's complete blood count readings reflect a reduced hematocrit.

Explanation:

During the intermediate phase of burn care, the client's hematocrit should diminish as a result of hemodilution, which occurs as the fluids shift back into the circulating blood volume from the tissues. In the intermediate phase of burn care, the client will experience serum sodium deficits. Urinary output increases during this phase as renal perfusion increases. Loss of serum sodium leads to metabolic acidosis, not metabolic alkalosis.

Determining the depth of a burn is difficult initially because there are combinations of injury zones in the same location. The following describes one of the injury zones: the area of intermediate burn injury. It is here that blood vessels are damaged, but tissue has the potential to survive. What is the name of that zone?

A Zone of stasis

B Zone of coagulation

C Zone of hypotension

D Zone of hyperemia

Zone of stasis

Explanation:

The zone of stasis is the area of intermediate burn injury. It is here that blood vessels are damaged, but tissue has the potential to survive. The zone of coagulation is at the center of the injury, and it is the area where the injury is most severe and usually deepest. The zone of hyperemia is the area of least injury, where the epidermis and dermis are only minimally damaged. This is not the name of one of the zones.

A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following?

A Superficial partial-thickness

B Full-thickness

C Deep partial-thickness

D Superficial

Full-thickness

Explanation:

A full-thickness burn involves total destruction of the dermis and extends into the subcutaneous fat. It can also involve muscle and bone. A superficial burn only damages the epidermis. In a superficial partial-thickness burn, the epidermis is destroyed and a small portion of the underlying dermis is injured. A deep partial-thickness burn extends into the reticular layer of the dermis and is hard to distinguish froma full-thickness burn. It is red or white, mottled, and can be moist or fairly dry.

A patient has been prescribed mafenide acetate (Sulfamylon) cream for burn treatment. The nurse should educate the patient regarding which of the following?

A Can be left in place for 3 to 5 days

B Blood levels of sodium and potassium will be monitored. C Stains clothing

D Severe burning pain for up to 20 minutes

Severe burning pain for up to 20 minutes

Explanation:

The patient should be premedicated with analgesic before applying mafenide acetate because this agent causes severe burning pain for up to 20 minutes after application. Silver nitrate stains everything it touches black. Acticoat dressings can be left in place for 3 to 5 days. Silver nitrate solution acts as a wick for sodium and potassium; serum levels of these electrolytes need to be monitored.

A patient is scheduled for an allograft to a burn wound. The patient asks what an allograft is. Which of the following information will the nurse include in the explanation?

A "An allograft is a temporary wound covering obtained from pig skin."

B "An allograft is a permanent wound covering taken from a donor site in your body."

C "An allograft is a temporary wound covering obtained from cadaver skin."

D "An allograft is an expensive sheet of skin obtained from a culture."

"An allograft is a temporary wound covering obtained from cadaver skin."

Explanation:

There are several different temporary and permanent coverings for burn wounds. Homografts (or allografts) and xenografts (or heterografts) are also referred to as biologic dressings and are intended to be temporary wound coverage. Homografts are skin obtained from recently deceased or living humans other than the patient. Xenografts consist of skin taken from animals (usually pigs). Therefore, the body's immune response will eventually reject them as a foreign substance.

The nurse is caring for a patient with superficial partial-thickness burn injuries to the lower extremities. The patient is ordered IV morphine for pain. The nurse understands narcotics are given IV to manage pain during the initial management of pain because of which of the following?

A Tissue edema may interfere with drug absorption via other routes.

B The patient can experience nausea and emesis when given oral medications.

C Pain resulting from a burn injury requires relief by the fastest route available.

D Bleeding may occur at injection sites when the intramuscular route is used.

Tissue edema may interfere with drug absorption via other routes.

Explanation:

IV administration is necessary because of altered tissue perfusion from the burn injury.

A patient with a burn wound is prescribed mafenide acetate 5% (Sulfamylon) twice daily. Nursing implications associated with this medication include which of the following?

A Monitoring the patient for the development of respiratory acidosis

B Premedicating the patient with an analgesic prior to application

C Monitoring the patient's Na+ and K+ serum levels and replace as prescribed

D Protecting the bed linens and patient's clothing from contact to prevent staining

Premedicating the patient with an analgesic prior to application

Explanation:

Mafenide is a strong carbonic anhydrase inhibitor and may cause metabolic acidosis. Application may cause considerable pain initially, thus premedicating the patient is an appropriate intervention. The other nursing implications are not associated with mafenide.

A patient presents to the ED following a burn injury. The patient has burns to the anterior chest and entire left leg. Using the rule of nines, the nurse documents the total body surface area (TBSA) percentage as which of the following?

A 27%

B 18%

C 36%

D 9%

36%

Explanation:

The rule-of-nines system is based on dividing anatomic regions, each representing approximately 9% of the TBSA, quickly allowing clinicians to obtain an estimate. If a portion of an anatomic area is burned, the TBSA is calculated accordingly—for example, if approximately half of the anterior leg is burned, the TBSA burned would be 4.5%. More specifically, with an adult who has been burned, the percent of the body involved can be calculated as follows: head = 9%, chest (front) = 9%, abdomen (front) = 9%, upper/mid/low back and buttocks = 18%, each arm = 9% (front = 4.5%, back = 4.5%), groin = 1%, and each leg = 18% total (front = 9%, back = 9%).

Acticoat antimicrobial barrier dressings used in the treatment of burn wounds can be left in place for which timeframe?

A 2 days

B 7 to 10 days

C 3 days

D 5 days

5 days

Explanation:

Acticoat antimicrobial barrier dressings can be left in place for up to 5 days thus helping to decrease discomfort to the patient, decrease costs of dressing supplies, and decrease nursing time involved in burn dressing changes.

Which of the following is the key sign of onset of ARDS?

A Chest pain

B Tachypnea

C Hypoxemia

D Stridor

Hypoxemia

Explanation:

The key sign of the onset of ARDS is hypoxemia while receiving 100% oxygen, with decreased lung compliance and significant shunting. The physician should be notified immediately of deteriorating respiratory status.

ll of the following are antimicrobials commonly used to treat burns except:

A Silver nitrate (AgNO3) 0.5% solution

B Mafenide (Sulfamylon)

C Tetracycline

D Silver sulfadiazine (Silvadene)

Tetracycline

Explanation:

Silver sulfadiazine (Silvadene), mafenide (Sulfamylon), and silver nitrate (AgNO3) 0.5% solution are the three major antimicrobials used to treat burns.

Which of the following topical burn preparations act as wick for sodium and potassium?

A Mafenide acetate (Sulfamylon)

B Silver sulfadiazine (Silvadene)

C Silver nitrate solution

D Acticoat

Silver nitrate solution

Explanation:

Silver nitrate solution is hypotonic and acts as a wick for sodium and potassium. The other preparations do not act as a wick for sodium and potassium.

Which of the following provides clues about fluid volume status? Select all that apply.

A Oxygen saturation

B Skin turgor

C Percentage of meals eaten

D Hourly urine output

E Daily weights

Hourly urine output

Daily weights

Explanation:

Monitoring of hourly urine output and daily weights provides clues about fluid volume status. Percentage of meals eaten, skin turgor, and oxygen saturation would not be reliable indicators of fluid volume status in the burn injured patient.

A patient with a severe electrical burn injury is being treated in the burn unit. Which of the following laboratory results would cause the nurse the most concern?

A Ca: 9 mg/dL

B K+: 5.0 mEq/L

C BUN: 28 mg/dL

D Na+: 145 mEq/L

BUN: 28 mg/dL

Explanation:

The elevated BUN would case the nurse the most concern. The nurse should report decreased urine output or increased BUN and creatinine values to the physician. These laboratory values indicate possible renal failure. In addition, myoglobinuria, which is associated with electrical burns, is common with muscle damage and may also cause kidney failure if not treated. The other values are within normal limits.

Which type of burn injury involves destruction of the epidermis and upper layers of the dermis and injury to the deeper portions of the dermis?

A Fourth degree

B Superficial partial-thickness

C Deep partial-thickness

D Full-thickness

Deep partial-thickness

Explanation:

A deep partial-thickness burn involves destruction of the epidermis and upper layers of the dermis and injury to deeper portions of the dermis. In a superficial partial-thickness burn, the epidermis is destroyed or injured and a portion of the dermis may be injured. Capillary refill follows tissue blanching. Hair follicles remain intact. A full-thickness burn involves total destruction of epidermis and dermis and, in some cases, destruction of underlying tissue, muscle, and bone. Although the term fourth-degree burn is not used universally, it occurs with prolonged flame contact or high voltage injury that destroys all layers of the skin and damages tendons and muscles.

Which type of débridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar?

A Natural

B Mechanical

C Surgical

D Chemical

Mechanical

Explanation:

Mechanical débridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar. Topical enzymatic débridement agents are available to promote débridement of the burn wounds. With natural débridement, the dead tissue separates from the underlying viable tissue spontaneously. Surgical débridement is an operative procedure involving either primary excision (surgical removal of tissue) of the full thickness of the skin down to the fascia (tangential excision) or shaving of the burned skin layers gradually down to freely bleeding, viable tissue.

Which of the following is an early sign of sepsis in the burn injured patient?

A Clammy skin

B Hypothermia

C Increased pulse rate

D Widened pulse pressure

Widened pulse pressure

Explanation:

The signs of early systemic sepsis are subtle and require a high index of suspicion and very close monitoring of changes in the patient's status. Early signs of sepsis may include increased temperature, increased pulse rate, widened pulse pressure, and flushed dry skin in unburned areas.

When the ED nurse learns that a patient suffered a burn injury from a flash flame, the nurse anticipates which depth of burn?

A Deep partial thickness

B Superficial

C Full thickness

D Superficial partial thickness

Deep partial thickness

Explanation:

A deep partial thickness burn, which is similar to a second-degree burn, is associated with scalds and flash flames. Superficial partial thickness burns, similar to first-degree burns are associated with sunburns. Full thickness burns, similar to third-degree burns, are associated with direct flame, electricity, and chemical contact. Injury from a flash flame is not associated with a burn that is limited to the epidermis.

Which of the following are possible indicators of pulmonary damage from an inhalation injury? Select all that apply.

A Facial burns

B Singed nasal hair

C Yellow sputum

D Bradypnea

E Hoarseness

Singed nasal hair

Hoarseness

Facial burns

Explanation:

Indicators of possible pulmonary damage include singed nasal hair, hoarseness, voice change, stridor, burns of the face or neck, sooty or bloody sputum, and tachypnea.

The most important intervention in the nutritional support of a patient with a burn injury is to provide adequate nutrition and calories to

A increase metabolic rate.

B increase glucose demands.

C increase skeletal muscle breakdown.

D decrease catabolism.

decrease catabolism.

Explanation:

The most important intervention in the nutritional support of a patient with a burn injury is to provide adequate nutrition and calories to decrease catabolism. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50%. A marked increase in metabolic rate is seen after a burn injury and interventions are instituted to decrease metabolic rate and catabolism. A marked increase in glucose demand is seen after a burn injury and interventions are instituted to decrease glucose demands and catabolism. Rapid skeletal muscle breakdown with amino acids serving as the energy source is seen after a burn injury and interventions are instituted to decrease catabolism.

Following a burn injury, which of the following areas is the priority for nursing assessment?

A Nutrition

B Cardiovascular system

C Pulmonary system

D Pain

Pulmonary system

Explanation:

Airway patency and breathing must be assessed during the initial minutes of emergency care. Immediate therapy is directed toward establishing an airway and administering humidified 100% oxygen. Pulmonary problems may be caused by the inhalation of heat and/or smoke or edema of the airway. Assessing a patent airway is always a priority after a burn injury followed by breathing. Remember the ABCs.

When using the palmar method to estimate the extent of the burn injury, the palm is equal to which percentage of TBSA?

1 3

2 2

3 4

4 .5

.5

Explanation:

In patients with scattered burns, or for a quick prehospital assessment, the palmer method may be used to estimate the extent of the burns. The size of the patient's palm, not including the surface area of the digits, is approximately 0.5% of the TBSA.

Tom Benson, a 42-year-old electrical lineman, suffered significant burns in a workplace accident. During his airlift to a regional burn unit, you assess his wounds taking care to find and mark his entrance and exit wounds. What occurrence makes it difficult to assess internal burn damage in electrical burns?

A Protein cell coagulation

B Continuing inflammatory process

C Deep tissue cooling

D All options are correct.

Deep tissue cooling

Explanation:

Because deep tissues cool more slowly than those at the surface, it is difficult initially to determine the extent of internal damage.

A patient is being discharged after sustaining a deep-partial thickness burn during a house fire. The patient is asking when the burn will be healed. The nurse understands that this type of burn injury heals within which of the following time frames?

A 8 weeks

B 2 to 4 weeks

C 1 week

D 6 weeks

2 to 4 weeks

Explanation:

For deep partial-thickness burn injuries, recovery is expected in 2 to 4 weeks.

The nurse understands that during the emergent/resuscitative phase of burn injury, hemoconcentration is due to which of the following?

A Sodium and water retention caused by increase adrenocortical activity

B Liquid blood component is lost into extravascular space

C Decreased renal blood flow

D Fluid loss

Liquid blood component is lost into extravascular space

Explanation:

Hemoconcentration is due to the blood component being lost into the extravascular space. Decreased urinary output occurs secondary to fluid loss, decreased renal blood flow, and sodium and water retention caused by increased adrenocortical activity.

The nurse is caring for a patient with extensive burn injuries. Which of the following parameters would the nurse evaluate to determine if the patient is receiving adequate fluid resuscitation? Select all that apply.

A Heart rate

B Oxygen saturation

C Blood pressure

D Urine output

Blood pressure

Heart rate

Urine output

Explanation:

Fluid resuscitation is administered to maintain adequate cardiac output and tissue perfusion. If adequate fluid is administered, tachycardia, hypotension, and oliguria will resolve. Expected outcomes of fluid resuscitation specifically include the following: urine output between 0.5 and 1.0 mL/kg/hr (30-50 mL/hr; 75 to 100 mL/hr if electrical burn injury), mean arterial pressure (MAP) pressure > 60 mm Hg, voids clear yellow urine with specific gravity within normal limits, and serum electrolytes are within normal limits

When is the first dressing change at the site of an autograft performed?

A As soon as foul odor or purulent drainage is noted, or 2 to 5 days after surgery

B Within 12 hours after surgery

C Within 24 hours after surgery

D As soon as sanguineous drainage is noted

As soon as foul odor or purulent drainage is noted, or 2 to 5 days after surgery

Explanation:

A foul odor or purulent infection may indicate infection and should be reported to the surgeon immediately. The first dressing change usually occurs 2 to 5 days after surgery. Sanguineous drainage on a dressing covering an autograft is an anticipated abnormal observation postoperatively.

A 57-year-old firefighter was severely burned fighting a house fire. During his aggressive treatment, the client begins to exhibit symptoms of renal failure. What physiologic process can cause acute renal failure?

A Hemoconcentration

B Anemia

C Histamine

D Fluid, electrolyte status

Hemoconcentration

Explanation:

The client with a burn experiences hemoconcentration when the plasma component of blood is lost or trapped. Myoglobin and hemoglobin are transported to the kidneys, where they may cause tubular necrosis and acute renal failure.

Several temporary and permanent sources are available for covering a burn wound. These may be manufactured synthetically, obtained from a biologic source, or a combination of the two. Select the graft described as the following: a biologic source of skin similar to that of the client.

A Allograft

B Slit graft

C Xenograft

D Autograft

Allograft

Explanation:

Allograft or homograft is a biologic source of skin similar to that of the client. A xenograft or heterograft is obtained from animals, principally pigs or cows. An autograft uses the client's own skin, transplanted from one part of the body to another. A slit graft is a type of autograft.

At the scene of a fire, the first priority is to prevent further injury. What are interventions at the site that can help to prevent injury? Choose all that apply.

A Roll the client in a blanket to smother the fire.

B Open door and encourage air in an enclosed space.

C Place the client in a horizontal position.

D Place the client in a vertical position.

Place the client in a horizontal position.

Roll the client in a blanket to smother the fire.

Explanation:

If the clothing is on fire, the client is placed in a horizontal position and rolled in a blanket to smother the fire.

Which zone of burn injury sustains the most damage?

A Middle

B Inner

C Outer

D Protective

Inner

Explanation:

Each burned area has three zones of injury. The inner zone (known as the area of coagulation, where cellular death occurs) sustains the most damage. The middle area, or zone of stasis, has a compromised blood supply, inflammation, and tissue injury. The outer zone, the zone of hyperemia, sustains the least damage.

ithin the practice of nursing at the burn unit, there are specific potential complications common to specific types of burns. Which burns can impair ventilation?

A All options are correct.

B Perineal

C Face, neck, chest

D Hands, major joints

Face, neck, chest

Explanation:

Burns of the face, neck, or chest have the potential to impair ventilation.

When using the Palmar method to estimate the extent of a small or scattered burn injury, the palm is equal to which percentage of total body surface area (TBSA)?

1 4

2 2

3 1

4 3

1

Explanation:

In patients with scattered burns, or for a quick prehospital assessment, the Palmer method may be used to estimate the extent of the burns. The size of the patient's palm, not including the surface area of the digits, is approximately 1% of the TBSA.

The nurse has completed teaching home care instructions to a patient being discharged from the burn unit. Which of the following patient statements indicates the need for further teaching?

A "I will wear sun block with the highest SPF possible to protect exposed burned skin from the sun."

B "I will drink a lot of fluids to prevent constipation since I am taking pain medications."

C "As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help."

D "I can work with the social worker to find funding assistance programs to help with my medical expenses."

"As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help."

Explanation:

Itching is a normal part of healing. Many patients describe this as one of the most uncomfortable aspects of burn recovery. The patient can apply mild moisturizers to decrease itching from dryness. Medications can be discussed with your treatment team. The patient should pat the areas, scratching is contraindicated. The other statements indicate that teaching has been effective.

A 6-year-old girl was playing near her family's campfire when she fell into the fire, suffering significant burns. She was taken by air ambulance to the burn unit where you practice nursing. What physiologic process furthers her burn injury?

A Hypertension

B Intravascular fluid excess

C Neuroendocrine

D Inflammatory

Inflammatory

Explanation:

The initial burn injury is further extended by inflammatory processes that affect layers of tissue below the initial surface injury.

Which of the following is the analgesic of choice for burn pain?

A Fentanyl

B Demerol

C Morphine sulfate

D Tylenol with codeine

Morphine sulfate

Explanation:

Morphine sulfate remains the analgesic of choice. It is titrated to obtain pain relief on the patient's self-report of pain. Fentanyl is particularly useful for procedural pain, because it has a rapid onset, high potency, and short duration, all of which make it effective for use with procedures. Demerol and Tylenol with codeine are not analgesics of choice for burn pain.

A patient is being cared for in a burn unit after suffering partial-thickness burns. The patient's laboratory work reveals a positive wound culture for gram-negative bacteria. The health care provider orders silver sulfadiazine (Silvadene) to be applied to the patient's burns. The nurse provides information to the patient about the medication. Which of the following statements made by the patient indicates an understanding about this treatment? Select all that apply.

A "This medication will help my burn heal."

B "This medication will stain my skin permanently."

C "This medication is an antibacterial."

D "This medication will be applied directly to the wound."

"This medication is an antibacterial."

"This medication will be applied directly to the wound."

"This medication will help my burn heal."

Explanation:

This medication is an antibacterial, which has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. This medication is directly applied to the wound. This medication will not stain the patient's skin, but it will help heal the patient's burned areas.

Which of the following measures can be used to cool a burn?

A Application of ice directly to burn

B Wrapping the person in ice

C Using cold soaks or dressings for at least 1 hour

D Application of cool water

Application of cool water

Explanation:

Once a burn has been sustained, the application of cool water is the best first-aid measure. 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.

Which of the following fluid or electrolyte changes occur in the emergent/resuscitative phase?

A Sodium excess

B Increased urinary output

C Reduction in blood volume

D Potassium deficit

Reduction in blood volume

Explanation:

A reduction in blood volume occurs secondary to plasma loss. Sodium deficit, potassium excess, and decreased urinary output occurs in this phase.

A patient has been prescribed Acticoat as a burn wound treatment. Which of the following is accurate regarding application of Acticoat?

A Moisten with saline.

B Use topical antimicrobials with Acticoat burn dressing.

C Keep Acticoat saturated.

D Moisten with sterile water only.

Moisten with sterile water only.

Explanation:

Acticoat is moistened with sterile water only; never use normal saline. Do not use topical antimicrobials with Acticoat burn dressing. Keep Acticoat moist, not saturated.

Which of the following is a potential cause of a superficial partial-thickness burn?

A Sunburn

B Scald

C Flash flame

D Electrical current

Sunburn

Explanation:

A potential cause of a superficial partial-thickness burn is a sunburn or low-intensity flash. Causes of deep partial-thickness burns are scalds and flash flames. Full-thickness burns may be caused by an electrical current or prolonged exposure to hot liquids.

The nurse is preparing to initiate fluid resuscitation for a patient weighing 130 pounds who suffered a 58% total body surface area (TBSA) thermal burn. The health care provider ordered: 2 mL lactated Ringer's (LR) × patient's weight in kilograms × %TBSA to be administered over 24 hours. The nurse will administer ________________________ mL of fluid over the first 8 hours post-burn injury?

3422

Explanation:

Convert pounds. to kilograms = 130/2.2 = 59 kg 2 mL × 59 kg × 58% TBSA = 6844 mL/24 hr. 6844/2 = 3422, so the nurse will administer 3422 mL over the first 8 hours and the remaining 3422 mL over the next 16 hours. The infusion is regulated so that one-half of the calculated volume is administered in the first 8 hours after burn injury. The second half of the calculated volume is administered over the next 16 hours. Fluid resuscitation formulas are only a guideline. It is imperative that the rate of infusion be titrated hourly as indicated by physiologic monitoring of the patient's response.

A patient has undergone grafting following a burn injury. The nurse understands that the first dressing change at the site of an autograft is performed how soon after the surgery?

A Within 12 hours after surgery

B 2 to 5 days after surgery

C As soon as sanguineous drainage is noted

D Within 24 hours after surgery

2 to 5 days after surgery

Explanation:

The first dressing change usually occurs 2 to 5 days after surgery. In addition, a foul odor or purulence may indicate infection and should be reported to the surgeon immediately. Sanguineous drainage on a dressing covering an autograft is an anticipated abnormal observation postoperatively

Which of the following interventions helps to minimize the risk of further injury to an affected person at a scene of a fire?

A Avoid immediate IV fluid therapy

B Cover the patient with a wet cloth

C Place the patient with the head positioned slightly below the rest of the body

D Roll the patient in a blanket

Roll the patient in a blanket

Explanation:

At the scene of a fire, the patient should be rolled in a blanket to smother the fire. The patient should be placed in a horizontal position to prevent the fire, hot air, and smoke from rising toward the head and entering the respiratory passage. The patient should not be covered immediately with a wet cloth or kept in any position other than horizontal. However, IV fluid therapy should be administered en route to the hospital.

The nurse is caring for a 30-year-old female patient who suffered severe head and facial burn injuries. Which of the following actions, if completed by the patient, indicates she is adapting to her altered body image? Select all that apply.

A Participates actively in daily activities

B Covers her face with a scarf

C Reports absence of sleep disturbance

D Wears hats and wigs

Wears hats and wigs

Participates actively in daily activities

Explanation:

The following are indicators that a patient is adapting to altered body image: verbalizes accurate description of alterations in body image and accepts physical appearance, demonstrates interest in resources that may improve function and perception of body appearance (e.g., uses cosmetics, wigs, and prostheses, as appropriate); socializes with significant others, peers, and usual social group; and seeks and achieves return to role in family, school, and community as a contributing member. Covering the face with a scarf indicates the patient is not adapting to the alteration in body image; absence of sleep disturbances is expected by the burn-injured patient but is not related to body image disturbance.

Which of the following is to be expected soon after a major burn? Select all that apply.

A Tachycardia

B Hypertension

C Hypotension

D Bradycardia

E Anxiety

Hypotension

Tachycardia

Anxiety

Explanation:

Tachycardia, slight hypotension, and anxiety are expected soon after the burn.

When providing care to a client who has experienced multiple trauma, which of the following would be most important for the nurse to keep in mind?

Injuries have occurred to at least three distinct organ systems.

The most lethal injuries are often the most readily apparent. The client is assumed to have a spinal cord injury until proven otherwise.

Most multiple trauma victims exhibit evidence of the trauma.

The client is assumed to have a spinal cord injury until proven otherwise.

Explanation:

With clients experiencing multiple trauma, the nurse must assume that the client has a spinal cord injury until proven otherwise. Multiple trauma cleints experience life-threatening injuries to at least two distinct organs or organ systems. Evidence of the trauma may be sparse or absent. Additionally, the injury that may seem the least significant may be the most lethal.

A nurse is providing an educational program for a group of occupational health nurses working in chemical facilities. Which of the following would the nurse include as the priority in the case of a chemical burn?

Covering the area with a sterile dressing

Rinsing the area with copious amounts of water

Applying antimicrobial ointment

Administering tetanus prophylaxis

Rinsing the area with copious amounts of water

Explanation:

The priority for any chemical burn is to immediately drench the area with running water, unless the chemical is lye or white phosphorus, which should be brushed off the patient. Antimicrobial ointments, sterile dressings, and tetanus prophylaxis are measures instituted later in the course of treatment, depending on the characteristics of the chemical agent and the size and location of the burn.