Question 1

A patient is admitted with a chemical burn caused by a malfunctioning oven-cleaner container. What should the nurse keep in mind about this type of burn? Select all that apply.

Accepted Answer

1. Alkalis, such as oven cleaners, result in more serious burns than acids because they are more difficult to neutralize, resulting in deeper tissue damage.
2. Alkalis, such as oven cleaners, result in more serious burns than acids because they are more difficult to neutralize, resulting in deeper tissue damage.
3. The extent of damage from a chemical is related to the amount and duration of contact with the skin.
4. Health care workers should be aware of risk to themselves or other patients and take appropriate cautions by remembering to wear personal protective equipment.
5. National, state, or local poison control centers should be contacted for information on how to neutralize the specific chemical agent.

Question 2

What interventions should the nurse plan to prevent the onset of contractures for a patient in the rehabilitation phase of burn care? Select all that apply.

Accepted Answer

1. Contractures are prevented by performing exercises as prescribed by physical therapy.
2. Contractures are prevented by joint splinting.
3. Contractures are prevented by appropriate body positioning.
4. Range-of-motion exercises are used to treat contractures.
5. Surgery to release the joints is used to treat contractures that are unresponsive to therapy and not to prevent contractures from developing.

Question 3

A patient has a superficial partial-thickness burn over the anterior portion of the right lower leg. What care should the nurse plan for this patient? Select all that apply.

Accepted Answer

1. Grafting would be appropriate for a full-thickness burn.
2. Splinting would be appropriate if the burn involved a joint area.
3. The focus of care for minor burns includes wound care.
4. An escharotomy is not indicated for this type of burn.
5. The focus of care for minor burns includes pain management.

Question 4

The nurse cares for a patient who was in a house fire. The patient currently has a hoarse voice and has soot in the sputum. Over the next 24 hours, what might the patient experience as manifestations of a lower airway injury? Select all that apply.

Accepted Answer

1. Chemical irritation of the alveolar tissue causes increased mucous production.
2. Chemical irritation of the alveolar tissue causes bronchospasm.
3. After 24 hours, the patient's chest x-ray may show the development of patchy atelectasis.
4. Chest pain is not a manifestation of a lower airway injury.
5. Peripheral neuropathy is not a manifestation of a lower airway injury.

Question 5

A patient is admitted with burns to both legs and one arm after being electrocuted while replacing a transformer during a thunderstorm. Since these limbs appear mummified, which treatment should the nurse anticipate being prescribed for this patient?

Accepted Answer

1. Burns caused by high-voltage electrical exposure may appear charred and mummified. Amputation is usually required.
2. The tissue is burned beyond healing. The limbs will need to be amputated.
3. Whirlpool and wet dressings will not help these burns. The limbs will need to be amputated.
4. An escharotomy and colloid dressings will not help these burns. The limbs will need to be amputated.

Question 6

The nurse assists with the initial debridement of a patient's burn wounds. What will be done during this debridement? Select all that apply.

Accepted Answer

1. Debridement of major burn wounds involves cleaning the burn wound with warm water or sterile saline and antimicrobial soaps or wound cleansers.
2. Debridement of major burn wounds involves removing loose skin with gauze.
3. Debridement of major burn wounds involves trimming skin tags with scissors.
4. Debridement of major burn wounds involves shaving the hair around the wound.
5. The debrided wound is washed with warm water or normal saline.

Question 7

A patient weighing 80 kg is receiving resuscitative care for a burn to 46% of total body surface area. What finding indicates that resuscitation is effective? Select all that apply.

Accepted Answer

1. Burn resuscitation is considered successful when the patient has adequate urine output after 2 hours of fluids administered at maintenance rate. The urine output should be 0.5 to 1.0 mL/kg/hr.
2. Acceptable parameters include a heart rate less than 120 beats per minute.
3. A blood pressure that is normal to slightly hypertensive is evidence of successful resuscitation.
4. Clear lung sounds are evidence of successful resuscitation.
5. Bladder pressure is not used to assess effectiveness of resuscitative care.

Question 8

A patient with 50% total body surface burns is recovering from graft surgery. What should the nurse identify as major goals of care for this patient? Select all that apply.

Accepted Answer

1. Because altered immune function is sustained throughout the healing phase, the burn patients may be susceptible to infections and colds. Appropriate precautions should be taken, including avoiding unnecessary exposure to people with colds or infections and maintaining up-to-date immunizations.
2. The maturing burn scar is fragile and susceptible to wound breakdown from shearing and pressure. Wound breakdown can occur after the patient is discharged from the hospital.
3. Hypertrophic scarring occurs most often along the edges of skin grafts. Hypertrophic scarring can be prevented or greatly reduced by the application of pressure garments.
4. Fluid resuscitation occurs during the resuscitation phase of burn care.
5. Exercise helps prevent the development of contractures after a major burn.

Question 9

During the acute phase of burn injury, the patient has the risk of developing complications. For what should the nurse assess the patient during this phase?

Accepted Answer

1. This would occur during the resuscitative phase due to large amounts of fluid loss.
2. During the acute phase, fluid resuscitation is complete and the patient is at risk for sepsis and septic shock.
3. This would occur during the rehabilitative phase as healing is occurring.
4. Even though the presence of an indwelling urinary catheter can contribute to a urinary tract infection, it is not unique to the burn patient.

Question 10

The critical care nurse is concerned that a patient in the acute phase of a burn injury is experiencing metabolic changes because of which assessment finding? Select all that apply.

Accepted Answer

1. Hypermetabolism causes a drop in body weight during the acute phase of a burn injury.
2. Hypermetabolism causes creatinine levels to increase during the acute phase of a burn injury.
3. Urine output is an indication of fluid and renal status effects and not a result of metabolic changes.
4. Abdominal pain is an indication of gastrointestinal status effects and not a result of metabolic changes.
5. Stridor is an indication of respiratory effects and not a result of metabolic changes.

Question 11

The nurse suspects that a patient with 40% total body surface area burned is developing gastrointestinal problems. What did the nurse assess to make this clinical determination? Select all that apply.

Accepted Answer

1. The systemic vasoconstriction caused by burn shock often results in the development of paralytic ileus and mucosal edema. The patient with paralytic ileus is at risk for hematemesis.
2. Abdominal pain is not a usual gastrointestinal symptom associated with a burn injury.
3. A board-like abdomen is not a usual gastrointestinal disorder associated with a burn injury.
4. Absent bowel sounds indicates a paralytic ileus.
5. The systemic vasoconstriction caused by burn shock often results in the development of paralytic ileus and mucosal edema. The patient with paralytic ileus is at risk for abdominal distention.

Question 12

The intensive care nurse assesses a patient for cardiovascular system changes related to a burn injury. Which findings are associated with a burn injury? Select all that apply.

Accepted Answer

1. With any type of shock, the patient would experience hypotension.
2. One cardiovascular change after a burn injury is peripheral extremity vascular compromise.
3. The most common cardiovascular change is hypovolemic burn shock.
4. One cardiovascular change after a burn injury is peripheral extremity vascular compromise.
5. One cardiovascular change after a burn injury is alteration in cardiac rhythm.

Question 13

The nurse cares for a patient who was brought into the emergency department after being struck by lightning. This patient's injuries will most likely be to which body areas? Select all that apply.

Accepted Answer

1. Electrical injury may result in cardiac dysrhythmias that can lead to cardiopulmonary arrest.
2. Electrical injuries may result in tissue destruction, which is not easily assessed.
3. Electrical injuries may result in bone destruction, which is not easily assessed.
4. Electrical injuries do not target the kidneys.
5. Electrical injuries do not target the lungs.

Question 14

A patient experiences high levels of anxiety following a house fire. The nurse should administer which medication to help reduce the anxiety?

Accepted Answer

1. Fentanyl would be used for pain management.
2. Anxiolytics such as lorazepam may be used if the patient is experiencing high anxiety.
3. Hydromorphone would be used for pain management.
4. Sertraline is an antidepressant, which can lower anxiety; however, it may take 4 weeks or more to be effective.

Question 15

The nurse plans a burn prevention program for older persons at a neighborhood association meeting. Which visual aid should the nurse use to emphasize the most common cause of burn injuries in an older adult?

Accepted Answer

1. Fires caused by smoking are the leading cause of death in the older adult.
2. Scalds are not the leading cause of burn injuries in the older adult.
3. The picture of the pots and pans would be the best visual aid because approximately 3,000 older adults are injured in residential fires each year, with cooking fires being the leading cause of injuries.
4. Electrical fires are not the leading cause of burn injuries in the older adult.

Question 16

After the initial assessment of burn injuries, it is determined that the patient will be transferred to a burn center for care. What assessment finding contributed to this decision? Select all that apply.

Accepted Answer

1. Burn injuries that should be referred to a burn center include burns to the face.
2. Burn injuries that should be referred to a burn center include burns to the hands.
3. Burn injuries that should be referred to a burn center include burns to major joints.
4. Burn injuries that should be referred to a burn center include burns to the perineum.
5. These burn injuries would not necessitate the patient to be transferred to a burn center.

Question 17

The nurse cares for an older patient with a burn injury. Because preexisting health conditions influence how the older patient responds to the resuscitative treatment, what should be the priority when caring for this patient?

Accepted Answer

1. This is not the immediate priority.
2. This is not the immediate priority.
3. This is not the immediate priority.
4. Based on the strategy of ABCs (airway, breathing, and circulation), fluid resuscitation is the greatest priority. The patient with heart problems must be closely monitored during fluid resuscitation, and a balance must be maintained between providing adequate resuscitation to the tissues and further stressing the heart.

Question 18

A patient sustained burns to the following body areas: both upper anterior arms, both lower anterior legs, and the anterior face and neck. Using the rule of nines, what is this patient's total body surface area burned? Record your answer rounding to one decimal place.

Accepted Answer

The answer of A patient sustained burns to the following...

Quiz 17: Care of the Acutely Ill Burn Patient