Question 1

A child is brought to the emergency department with burns from hot liquid pulled from the stove. Which information is most important for the nurse to acquire from the accompanying adult?

Accepted Answer

Identification of the substance causing the injury is crucial for determining the appropriate treatment and potential complications. Different substances can cause burns of varying severity and may require specific interventions.

Question 2

The nurse on a burn rehabilitation unit presents information addressing the incidence of postburn itching. Which information from researching the topic will the nurse identify as incorrect?

Accepted Answer

Scratching the opposite part of the body to stop itching is not a recognized or effective method for managing postburn itching. Effective management often includes pharmacological and nonpharmacological interventions, and itching can indeed interfere with daily activities and recovery. Techniques such as massage with soothing lotion are considered beneficial in managing itching.

Question 3

The nurse is providing care for a patient with burns covering the entire surface of both arms and the anterior trunk. Approximately what percentage of the patient's body surface area has been affected?

Accepted Answer

According to the Rule of Nines in burn assessment, each arm accounts for 9% of the body surface area, and the anterior trunk accounts for 18%. Therefore, both arms (9% + 9% = 18%) plus the anterior trunk (18%) equals 36% of the body surface area.

Question 4

The nurse is working on the rehabilitation unit in a burn facility. The nurse has been reinforcing the importance of returning the patient to an optimal level of physical functioning. Which statement by the patient indicates a lack of understanding?

Accepted Answer

The statement "I can now feed myself and that makes me independent enough." indicates a lack of understanding because it suggests the patient has set a very low bar for their recovery and independence. Rehabilitation aims for the highest level of physical functioning possible, not just basic self-care.

Question 5

The nurse is providing care for a patient in the emergent stage of treatment for a partial-thickness burn. The patient has been stabilized, with blood pressure 140/88 mm Hg, pulse 78 beats/min, respirations 22 breaths/min, and temperature 97.4°F (36.3°C) orally. Which new assessment finding does the nurse immediately communicate to the health care provider (HCP)?

Accepted Answer

The answer of The nurse is providing care for a...

Question 6

The nurse is assisting with the care of a patient with second-degree burns to 35 percent of the body. Five hours after the burn occurs, the HCP prescribes nasogastric (NG) enteral feedings. For which reason does the nurse understand the value of the NG feedings and the importance of the time frame?

Accepted Answer

The answer of The nurse is assisting with the care...

Question 7

The nurse is preparing a patient with 46 percent total body surface area burned for graft placement. Which anatomical locations does the nurse expect to have a lower rate of graft success than other areas of the body? (Select all that apply.)

Accepted Answer

Areas with a lower rate of graft success typically include the axillae, buttocks, perineum, and joint areas due to factors like constant movement, moisture, and bacterial colonization, which can interfere with graft take and healing.

Question 8

A patient receives extensive burns to the face, chest, and hands from a random act of violence. The patient states, "I was doing so well, but I will never fit in again with my family, friends, or coworkers." The nurse identifies which need for this patient?

Accepted Answer

The patient's statement reflects concerns about self-esteem and fitting in, indicating a need for professional psychiatric counseling to address these emotional and psychological issues.

Question 9

The nurse notes that a patient with full thickness burns has an increase in hematocrit level. What does the nurse realize is causing this change in laboratory value?

Accepted Answer

The increase in hematocrit level in a patient with full thickness burns is primarily due to the loss of intravascular fluid. This loss leads to hemoconcentration, where the proportion of red blood cells in the blood is increased because there is less plasma volume, not because there is an actual increase in red blood cells.

Question 10

The nurse is assisting with the care of an older adult patient who is hospitalized for second-degree burns of the legs and feet acquired when a deep fryer tipped over. Which factor has the least impact on the condition and recovery of the patient?

Accepted Answer

The type of clothing worn at the time of the injury, such as light-weight cotton pajamas, has the least impact on the condition and recovery of the patient compared to the other factors listed. The condition of the skin, the substance causing the burns, and existing health conditions like diabetes mellitus significantly influence the severity of the burns and the healing process.

Question 11

The nurse is assisting with the care of a patient admitted to the emergency department with chemical burns across the chest and hands. Which actions are included in the plan of care? (Select all that apply.)

Accepted Answer

The answer of The nurse is assisting with the care...

Question 12

The nurse is providing care for a patient who is receiving fluid replacement after being burned on 37 percent of the body. Nursing assessment reveals a blood pressure of 80/60 mm Hg, pulse of 120 beats/min, and urine output of 10 mL over the past hour. After reporting these findings, which order does the nurse expect to be prescribed for this patient?

Accepted Answer

The patient is showing signs of hypovolemia (low blood pressure, high pulse rate, and low urine output), indicating that the current fluid replacement is insufficient. Increasing the IV fluid rate can help restore adequate circulation and improve urine output.

Question 13

The nurse is providing care for a patient who received synthetic dressings over partial-thickness burns. Which comment by the patient indicates to the nurse that additional information is needed about the procedure?

Accepted Answer

Synthetic dressings over partial-thickness burns do not grow; they are a temporary solution to protect the wound and reduce infection risk until the patient's own skin can heal or be grafted. The patient's misunderstanding that the synthetic grafts could grow indicates a need for further education.

Question 14

The nurse is providing care for a patient admitted to the burn unit with burns to 45 percent of the body. After 3 days, the nurse notes that the patient's temperature is newly elevated at 100.2°F (37.9°C), and the patient exhibits new-onset agitation and confusion. Which action does the nurse take first?

Accepted Answer

The first action the nurse should take is to notify the registered nurse (RN) or healthcare provider (HCP) because new-onset agitation, confusion, and a fever in a burn patient could indicate an infection or other serious complication that requires immediate assessment and potential intervention.

Question 15

The nurse is assisting in the care of a patient with a circumferential burn to the leg. The health care provider determines that an escharotomy is necessary. Which action does the nurse recognize as the most important nursing intervention?

Accepted Answer

Checking for the return of distal pulses is crucial after an escharotomy for a circumferential burn to ensure that blood flow to the area below the burn is not compromised. This helps in assessing the effectiveness of the procedure in relieving pressure and restoring circulation.

Quiz 55: Nursing Care of Patients With Burns