Lewis Chapter 26: Burns

1. 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. Full-thickness skin destruction

With full-thickness skin destruction, the appearance is pale and dry or leathery and the area is painless because of the associated nerve destruction. Erythema, swelling, and blisters point to a deep partial-thickness burn. With superficial partial-thickness burns, the area is red, but no blisters are present. First-degree burns exhibit erythema, blanching, and pain.

2. 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. Increase the rate of the ordered IV solution.

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.

3. 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. Notify the health care provider and prepare for endotracheal intubation.

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.

4. 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. 938 mL/hour

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.

5. 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. Measure hourly urine output.

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.

6. 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. Insert a feeding tube and initiate enteral feedings.

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.

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

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.

8. 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. Elevate the right arm and hand on pillows and extend the fingers.

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.

9. 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. Notify the health care provider.

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.

10. 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. Stools for occult blood

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.

11. 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. Hydromorphone (Dilaudid)

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

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

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.

13. 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. Continue to monitor the urine output.

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.

14. 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. Vanilla milkshake

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.

15. 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. Extremity movement

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.

16. 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. Remove nonadherent clothing and watch.

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.

17. 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. Use pulse oximetry to check the oxygen saturation.

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.

18. 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. Auscultate the patient's lung sounds.

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.

19. 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. Place on cardiac monitor.

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.

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

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.

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

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.

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

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.

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

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.

24. 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. Serum potassium 6.1 mEq/L

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.

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

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.

26. 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. Stabilize the cervical spine.

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.

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

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.

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

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.

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?

ANS:

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.

The nurse estimates the extent of a burn using the rule of nines for a patient who has been admitted with deep partial-thickness burns of the anterior trunk and the entire left arm. What percentage of the patient's total body surface area (TBSA) has been injured?

ANS:

27%

When using the rule of nines, the anterior trunk is considered to cover 18% of the patient's body and each arm is 9%.

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.

In caring for a patient with burns to the back, the nurse knows that the patient is moving out of the emergent phase of burn injury when what is observed?

a. Serum sodium and potassium increase.

b. Serum sodium and potassium decrease.

c. Edema and arterial blood gases improve.

d. Diuresis occurs and hematocrit decreases.

d. Diuresis occurs and hematocrit decreases.

In the emergent phase, the immediate, life-threatening problems from the burn, hypovolemic shock and edema, are treated and resolved. Toward the end of the emergent phase, fluid loss and edema formation end. Interstitial fluid returns to the vascular space and diuresis occurs. Urinary output is the most commonly used parameter to assess the adequacy of fluid resuscitation. The hemolysis of red blood cells (RBCs) and thrombosis of burned capillaries also decreases circulating RBCs. When the fluid balance has been restored, dilution causes the hematocrit levels to drop. Initially sodium moves to the interstitial spaces and remains there until edema formation ceases, so sodium levels increase at the end of the emergent phase as the sodium moves back to the vasculature. Initially potassium level increases as it is released from injured cells and hemolyzed RBCs so potassium levels decrease at the end of the emergent phase when fluid levels normalize.

A patient is admitted to the burn unit with second- and third-degree burns covering the face, entire right upper extremity, and right anterior trunk area. Using the rule of nines, what should the nurse calculate the extent of these burns as being?

a. 18%

b. 22.5%

c. 27%

d. 36%

b. 22.5%

Using the rule of nines, for these second- and third-degree burns, the face encompasses 4.5% of the body area, the entire right arm encompasses 9% of the body area, and the entire anterior trunk encompasses 18% of the body area. Because the patient has burns on only the right side of the anterior trunk, the nurse would assess that burn as encompassing half of the 18%, or 9%. Therefore, adding the three areas together (4.5 + 9 + 9), the nurse would correctly calculate the extent of this patient's burns to cover approximately 22.5% of the total body surface area.

A patient with a burn inhalation injury is receiving albuterol for the treatment of bronchospasm. What is the most important adverse effect of this medication for the nurse to monitor?

a. Tachycardia

b. Restlessness

c. Hypokalemia

d. Gastrointestinal (GI) distress

a. Tachycardia

Albuterol stimulates ß-adrenergic receptors in the lungs to cause bronchodilation. However, it is a noncardioselective agent so it also stimulates the ß-receptors in the heart to increase the heart rate. Restlessness and GI upset may occur but will decrease with use. Hypokalemia does not occur with albuterol.

The patient received a cultured epithelial autograft (CEA) to the entire left leg. What should the nurse include in the discharge teaching for this patient?

a. Sit or lie in the position of comfort.

b. Wear a pressure garment for 8 hours each day.

c. Refer the patient to a counselor for psychosocial support.

d. Use the sun to increase the skin color on the healed areas.

c. Refer the patient to a counselor for psychosocial support.

In the rehabilitation phase, the patient will work toward resuming a functional role in society, but frequently there are body image concerns and grieving for the loss of the way the patient looked and functioned before the burn, so continued counseling helps the patient in this phase as well. Putting the leg in the position of comfort is more likely to lead to contractures than to help the patient. If a pressure garment is prescribed, it is used for 24 hours per day for as long as 12 to 18 months. Sunlight should be avoided to prevent injury, and sunscreen should always be worn when the patient is outside.

Which patient should the nurse prepare to transfer to a regional burn center?

a. A 25-yr-old pregnant patient with a carboxyhemoglobin level of 1.5%

b. A 39-yr-old patient with a partial-thickness burn to the right upper arm

c. A 53-yr-old patient with a chemical burn to the anterior chest and neck

d. A 42-yr-old patient who is scheduled for skin grafting of a burn wound

c. A 53-yr-old patient with a chemical burn to the anterior chest and neck

The American Burn Association (ABA) has established referral criteria to determine which burn injuries should be treated in burn centers where specialized facilities and personnel are available to handle this type of trauma. Patients with chemical burns should be referred to a burn center. A normal serum carboxyhemoglobin level for nonsmokers is 0% to 1.5% and for smokers is 4% to 9%. Skin grafting for burn wound management is not a criterion for a referral to a burn center. Partial-thickness burns greater than 10% total body surface area (TBSA) should be referred to a burn center. A burn to the right upper arm is 4% TBSA.

An older adult patient is moving into an independent living facility. What teaching will prevent this patient from being accidently burned in the new home?

a. Cook for her.

b. Stop her from smoking.

c. Install tap water anti-scald devices.

d. Be sure she uses an open space heater.

c. Install tap water anti-scald devices.

Installing tap water anti-scald devices will help prevent accidental scald burns that more easily occur in older people as their skin becomes drier and the dermis thinner. Cooking for her may be needed at times of illness or in the future, but she is moving to an independent living facility, so at this time she should not need this assistance. Stopping her from smoking may be helpful to prevent burns but may not be possible without the requirement by the facility. Using an open space heater would increase her risk of being burned and would not be encouraged.

A patient is admitted to the emergency department with first- and second-degree burns after being involved in a house fire. Which assessment findings would alert the nurse to the presence of an inhalation injury (select all that apply.)? FOUR answers

Select all that apply.

a. Singed nasal hair

b. Generalized pallor

c. Painful swallowing

d. Burns on the upper extremities

e. History of being involved in a large fire

A,B,C,E

a. Singed nasal hair

b. Generalized pallor

c. Painful swallowing

e. History of being involved in a large fire

Reliable clues to the occurrence of inhalation injury is the presence of facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral and nasal membranes, carbonaceous sputum, history of being burned in an enclosed space, altered mental status, and "cherry red" skin color.

A patient with type 2 diabetes mellitus is in the acute phase of burn care with electrical burns on the left side of the body and a serum glucose level of 485 mg/dL. What is the nurse's priority intervention for this patient?

a. Replace the blood lost.

b. Maintain a neutral pH.

c. Maintain fluid balance.

d. Replace serum potassium.

c. Maintain fluid balance.

This patient is most likely experiencing hyperosmolar hyperglycemic syndrome (HHS). HHS dehydrates a patient rapidly. Thus HHS combined with the massive fluid losses of a burn tremendously increase this patient's risk for hypovolemic shock and serious hypotension. This is clearly the nurse's priority because the nurse must keep up with the patient's fluid requirements to prevent circulatory collapse caused by low intravascular volume. There is no mention of blood loss. Fluid resuscitation will help to correct the pH and serum potassium abnormalities.

The nurse is caring for a patient with partial- and full-thickness burns to 65% of the body. When planning nutritional interventions for this patient, what dietary choices should the nurse implement?

a. Full liquids only

b. Whatever the patient requests

c. High-protein and low-sodium foods

d. High-calorie and high-protein foods

d. High-calorie and high-protein foods

A hypermetabolic state occurs proportional to the size of the burn area. Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. Caloric needs are often in the 5000-kcal range. Failure to supply adequate calories and protein leads to malnutrition and delayed healing.

The nurse is planning care for the patient in the acute phase of a burn injury. What nursing action is important for the nurse to perform after the progression from the emergent to the acute phase?

a. Begin IV fluid replacement.

b. Monitor for signs of complications.

c. Assess and manage pain and anxiety.

d. Discuss possible reconstructive surgery.

b. Monitor for signs of complications.

Monitoring for complications (e.g., wound infection, pneumonia, contractures) is needed in the acute phase. Fluid replacement occurs in the emergent phase. Assessing and managing pain and anxiety occurs in the emergent and the acute phases. Discussing possible reconstructive surgeries is done in the rehabilitation phase.

The nurse is providing emergent care for a patient with a possible inhalation injury sustained in a house fire. The patient is anxious and disoriented, and the skin is a cherry red color. What is the priority action by the nurse?

a. Administer 100% humidified oxygen.

b. Teach the patient deep breathing exercises.

c. Encourage the patient to express his feelings.

d. Assist the patient to a high Fowler's position.

a. Administer 100% humidified oxygen.

Carbon monoxide (CO) poisoning may occur in house fires. CO displaces oxygen on the hemoglobin molecule resulting in hypoxia. High levels of CO in the blood result in a skin color that is described as cherry red. Hypoxia may cause anxious behaviors and altered mental status. Emergency treatment for inhalation injury and CO poisoning includes the immediate administration of 100% humidified oxygen. The other interventions are appropriate for inhalation injury but are not as urgent as oxygen administration.

The nurse is caring for a patient who sustained a deep partial-thickness burn to the anterior chest area during a workplace accident 6 hours ago. Which assessment findings would the nurse identify as congruent with this type of burn?

a. Skin is hard with a dry, waxy white appearance.

b. Skin is shiny and red with clear, fluid-filled blisters.

c. Skin is red and blanches when slight pressure is applied.

d. Skin is leathery with visible muscles, tendons, and bones.

b. Skin is shiny and red with clear, fluid-filled blisters.

Deep partial-thickness burns have fluid-filled vesicles that are red and shiny. They may appear wet (if vesicles have ruptured), and mild to moderate edema may be present. Superficial partial-thickness burns are red and blanch with pressure vesicles that appear 24 hours after the burn injury. Full-thickness burns are dry, waxy white, leathery, or hard, and there may be involvement of muscles, tendons, and bones.

When teaching the patient in the rehabilitation phase of a severe burn about the use of range-of-motion (ROM), what explanations should the nurse give to the patient (select all that apply.)?

Select all that apply. TWO answers

a. The exercises are the only way to prevent contractures.

b. Active and passive ROM maintain function of body parts.

c. ROM will show the patient that movement is still possible.

d. Movement facilitates mobilization of leaked exudates back into the vascular bed.

e. Active and passive ROM can only be done while the dressings are being changed.

B,C

b. Active and passive ROM maintain function of body parts.

c. ROM will show the patient that movement is still possible.

Active and passive ROM maintains function of body parts and reassures the patient that movement is still possible are the explanations that should be used. Contractures are prevented with ROM as well as splints. Movement facilitates mobilization of fluid in interstitial fluid back into the vascular bed. Although it is good to collaborate with physical therapy to perform ROM during dressing changes because the patient has already taken analgesics, ROM can and should be done throughout the day.

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 will the nurse include in this patient's care (select all that apply.)? FOUR answers

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

a. Escharotomy

c. IV and oral pain medications

d. Daily cleansing and debridement

e. Application of topical antimicrobial agent.

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.

The nurse is caring for a 71-kg patient during the first 12 hours after a thermal burn injury. Which outcomes indicate adequate fluid resuscitation (select all that apply.)? TWO answers

a. Urine output is 46 mL/hr.

b. Heart rate is 94 beats/min.

c. Urine specific gravity is 1.040.

d. Mean arterial pressure is 54 mm Hg.

e. Systolic blood pressure is 88 mm Hg.

A,B

a. Urine output is 46 mL/hr

b. Heart rate is 94 beats/min.

Assessment of the adequacy of fluid resuscitation is best made using either urine output or cardiac factors. Urine output should be 0.5 to 1 mL/kg/hr (or 75 to 100 mL/hr for an electrical burn patient with evidence of hemoglobinuria/myoglobinuria). Cardiac factors include a mean arterial pressure (MAP) greater than 65 mm Hg, systolic BP greater than 90 mm Hg, heart rate less than 120 beats/min. Normal range for urine specific gravity is 1.003 to 1.030.

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 4 hours.

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

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

c. 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.

When caring for a patient with an electrical burn injury, which order from the health care provider should the nurse question?

a. Mannitol 75 g IV

b. Urine for myoglobulin

c. Lactated Ringer's solution at 25 mL/hr

d. Sodium bicarbonate 24 mEq every 4 hours

c. Lactated Ringer's solution at 25 mL/hr.

Electrical injury puts the patient at risk for myoglobinuria, which can lead to acute renal tubular necrosis (ATN). Treatment consists of infusing lactated Ringer's solution at 2 to 4 mL/kg/%TBSA, a rate sufficient to maintain urinary output at 75 to 100 mL/hr. Mannitol can also be used to maintain urine output. Sodium bicarbonate may be given to alkalinize the urine. The urine would also be monitored for the presence of myoglobin. An infusion rate of 25 mL/hr is not sufficient to maintain adequate urine output in prevention and treatment of ATN.

The patient in the emergent phase of a burn injury is being treated for severe pain. What medication should the nurse anticipate administering to the patient?

a. Subcutaneous (SQ) tetanus toxoid

b. Intravenous (IV) morphine sulfate

c. Intramuscular (IM) hydromorphone

d. Oral oxycodone and acetaminophen

b. Intravenous (IV) morphine sulfate.

IV medications are used for burn injuries in the emergent phase to rapidly deliver relief and prevent unpredictable absorption as would occur with the IM route. The PO route is not used because GI function is slowed or impaired because of shock or paralytic ileus, although oxycodone and acetaminophen may be used later in the patient's recovery. Tetanus toxoid may be administered but not for pain.

A patient arrives in the emergency department after sustaining a full-thickness thermal burn to both arms while putting lighter fluid on a grill. What manifestations should the nurse expect?

a. Severe pain, blisters, and blanching with pressure

b. Pain, minimal edema, and blanching with pressure

c. Redness, evidence of inhalation injury, and charred skin

d. No pain, waxy white skin, and no blanching with pressure

d. No pain, waxy white skin, and no blanching with pressure

With full-thickness burns, the nerves and vasculature in the dermis are destroyed so there is no pain, the tissue is dry and waxy-looking or may be charred, and there is no blanching with pressure. Severe pain, blisters, and blanching occur with partial-thickness (deep, second-degree) burns. Pain, minimal edema, blanching, and redness occur with partial-thickness (superficial, first-degree) burns.

The nurse is planning to change the dressing that covers a deep partial-thickness burn of the right lower leg. Which prescribed medication should the nurse administer to the patient 30 minutes before the scheduled dressing change?

a. Morphine

b. Sertraline

c. Zolpidem

d. Enoxaparin

a. Morphine.

Deep partial-thickness burns result in severe pain related to nerve injury. The nurse should plan to administer analgesics before the dressing change to promote patient comfort. Morphine is a common opioid used for pain control. Sedative/hypnotics and antidepressant agents also can be given with analgesics to control the anxiety, insomnia, and depression that patients may experience. Zolpidem promotes sleep. Sertraline is an antidepressant. Enoxaparin is an anticoagulant.

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.