Deck 51: Coordinating Care for Patients With Burns

Question 1

The nurse monitors for which assessment findings in the patient admitted with superficial partial-thickness burns over both anterior lower arms?
1)Dry with no blisters
2)Waxy appearance and cherry red color
3)Dry leathery appearance and pale or brown color
4)Open or closed blisters, mild edema, easily blanches

Answer 1

4

Question 2

A patient has full-thickness burns over 30% of total body surface area. Which intervention to address the patient's comfort does the nurse question?
1)Elevate injured extremities.
2)Medicate for pain around the clock.
3)Apply medicated ointment to all areas.
4)Elevate the head of the bed 30 degrees.

Answer 2

2

Question 3

A victim of a house fire is brought to the emergency department for burn treatment. The nurse correlates which assessment to an inhalation injury?
1)Coughing
2)Soot on the face
3)Singed facial hair
4)Heart rate 98 bpm

Answer 3

3

Question 4

A patient with several deep partial-thickness burns asks how long it will take for the burn to heal. What is the nurse's best response?
1)"More than 2 weeks."
2)"Within 1 to 2 weeks."
3)"Within 24 to 72 hours."
4)"You will need skin grafts."

Question 5

A patient recovering from 25% total body surface area burns has a low-grade fever. What actions are the priority for the nurse to reduce this patient's risk of developing an infection?
1)Following contact precautions
2)Implementing protective isolation
3)Using sterile technique for all dressing changes
4)Administering prophylactic antibiotics as prescribed

Question 6

The nurse is caring for a patient who sustained electrical burns. What is the rationale for monitoring this patient for compartment syndrome?
1)Potential for undiagnosed injuries
2)Injuries from being thrown bruise soft tissue
3)Electrical current alters integrity of blood vessels
4)Fluid seeps from intravascular spaces into the interstitium

Question 7

The nurse provides care to a patient who sustained burns on 75% of the body. Which data requires the nurse to notify the healthcare provider?
1)Pain rating of 8 on a 1 to 10 point scale
2)Heart rate 90 bpm
3)Urine output 2 mL/kg per hour
4)Blood pressure 96/50 mm Hg

Question 8

In providing care to a victim of a car fire who is confused, dizzy, and nauseated, the nurse recognizes the need for which diagnostic test to determine if this patient is experiencing carbon monoxide poisoning?
1)Arterial blood gas (ABG)
2)Bronchoscopy
3)Pulse oximeter
4)Carboxyhemoglobin level

Question 9

A patient with 55% total body surface area burned received two-thirds of the required fluid resuscitation. For which potential problem should the nurse prepare to provide care to this patient?
1)Increased zone of stasis
2)Increased zone of hyperemia
3)Increased zone of coagulation
4)Decreased zone of coagulation

Question 10

The nurse is caring for a patient with 45% total body surface area thermal burns. The nurse monitors for which laboratory result?
1)Increased pH
2)Increased sodium
3)Increased potassium
4)Decreased hematocrit

Question 11

The nurse is preparing an educational tool to instruct community members on burn prevention. What does the nurse include as the most common injury in children younger than age 5?
1)Scald
2)Flame
3)Chemical
4)Carbon monoxide poisoning

Question 12

The nurse administers a large dose of the prescribed opioid analgesic in preparation for a dressing change for a patient with significant burn injury. What is the nurse's priority in this situation?
1)Ensuring a bag and mask is at the bedside
2)Asking the patient, "Are you allergic to any medications?"
3)Documenting the level of pain before medication administration
4)Evaluating the patient's level of pain after medication administration

Question 13

In providing care to a patient with 70% total body surface area chemical burns, the nurse correlates which as most effective in meeting this patient's nutritional needs?
1)Parenteral nutrition
2)Duodenal tube feedings
3)Nasogastric tube feedings
4)Six small high-calorie meals per day

Question 14

In providing care to a patient admitted with a suspected inhalation injury, what nursing action in the priority?
1)Administering intravenous lactated Ringer's fluid
2)Turning in bed every 2 hours
3)Monitoring intake and output
4)Administering 100% humidified oxygen

Question 15

The nurse provides care to a patient who is in the emergency department (ED) with a burn injury. What is the priority action by the nurse during the emergent phase of care?
1)Providing pain medications
2)Placing an indwelling urinary catheter
3)Administering the prescribed high-flow 100% oxygen by mask
4)Inserting two large-bore intravenous catheters in preparation for fluid resuscitation

Question 16

A patient presents to the emergency room seeking treatment for radiation burns. What needs to be considered before providing care to this patient?
1)Pathway of flow through the body
2)Duration of contact with the agent
3)Type, dose, and length of exposure
4)Temperature to which the skin is heated

Question 17

The nurse is evaluating care provided to a patient with burns during the emergent phase. Which data indicate that additional fluid resuscitation is required?
1)Blood pH 7.39
2)Heart rate 112 bpm
3)Blood pressure 110/60 mm Hg
4)Central venous pressure 2 mm Hg

Question 18

In caring for patient with 50% total body surface area burns, the nurse correlates which finding to resolution of burn shock?
1)Heart rate 112 bpm
2)Respirations 24 per minute
3)Blood pressure 90/60 mm Hg
4)Urine output 800 mL over 2 hours

Question 19

A patient with deep partial-thickness wounds is receiving enzymatic debridement. What assessment data does the nurse correlate to successful wound care treatment?
1)Gray wound bed
2)Separation of eschar
3)Development of eschar
4)Presence of purulent exudate

Question 20

The nurse is assisting with the secondary survey of a patient with 50% total body surface area electrical burns. Which test would be a priority for this patient?
1)Chest x-ray
2)Bronchoscopy
3)Computed tomography (CT) scan of the head 4.12-lead electrocardiogram

Question 21

In caring for a patient who sustained chemical burns, the nurse correlates which as potential causes of these injuries? Select all that apply.
1)Lime
2)Gasoline
3)Bleach
4)Fabric softener
5)Hydrofluoric acid

Question 22

The nurse is evaluating the nutritional status of a patient recovering from 24% total body surface area burns. Which data indicate adequate nutritional status?
1)Urine output of 50 mL/hour
2)Serum protein level 7.1 g/dL
3)Serum albumin level 2.8 g/dL
4)+1 pitting edema of lower extremities

Question 23

The school nurse is preparing material for National Fire Prevention Week. What information should be added to the classroom posters? Select all that apply.
1)Never leave a burning candle unattended.
2)Set heating pads on "low" when sleeping.
3)Keep a flashlight and telephone near the bed.
4)Check smoke alarm batteries every 12 months.
5)Never use the oven as a method to warm the home.

Question 24

A patient has been recovering for 18 months from burns that affected 60% total body surface area. For which complications does the nurse provide care to this patient? Select all that apply.
1)Hyperkalemia
2)Depression
3)Fluid volume deficit
4)Body image disorder
5)Post-traumatic stress disorder (PTSD)

Question 25

An adult patient received burns over both upper and lower arms, both hands, anterior upper and lower legs, anterior chest, and the neck. Using the following as a guide, what is this patient's total body surface percentage of area burned?
Text Figure 51.8

Question 26

A patient is ending the first year of recovery after having burns to both legs. Which observation indicates that the patient needs to be encouraged to wear the pressure garment?
1)Skin warm and moist
2)Pedal pulses present but faint
3)Scattered areas of scarring noted
4)Nonpitting edema of both ankles

Question 27

A patient weighing 187 lbs. has 38% total body surface area burns. Using the Advanced Burn Life Support resuscitation guidelines, how much fluid should this patient receive over the first 8 hours after the burn occurred? Record the answer as a whole number. ______

Question 28

A patient is diagnosed with several superficial partial-thickness burns. What treatment would be indicated for this patient if the blisters are broken? Select all that apply.
1)Apply bacitracin ointment.
2)Cover with a nonadherent bandage.
3)Apply mafenide acetate 10% cream.
4)Wash with antiseptic soap and warm water.
5)Apply collagenase and cover with roll gauze.

Question 29

The nurse provides care to an adult patient with burns over 36% of the body. The patient's current weight is 110 lbs. (50 kg). Using the Advance Burn Life Support guidelines, what is the total volume the patient needs to receive in the first 24 hours after the burn?

Question 30

The nurse provides care to a 40-year-old patient with burns on 24% of the body. The patient's current weight is 110 lbs. (50 kg). The patient received fluid resuscitation for 8 hours using the Advanced Burn Life Support (ABLS) guidelines. At what rate (mL/hour) does the nurse set the pump for the patient to receive the remaining fluid over the next 16 hours? Record as a number with no units of measurement.