Question 1

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.

Accepted Answer

The answer of In which order will the nurse take...

Question 2

Which patient should the nurse assess first?

Accepted Answer

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.

Question 3

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?

Accepted Answer

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.

Question 4

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?

Accepted Answer

The answer of An 80-kg patient with burns over 30%...

Question 5

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?

Accepted Answer

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.

Question 6

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?

Accepted Answer

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.

Question 7

Which nursing action is a priority for a patient who has suffered a burn injury while working on an electrical power line?

Accepted Answer

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.

Question 8

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?

Accepted Answer

The answer of The nurse estimates the extent of a...

Question 9

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?

Accepted Answer

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.

Question 10

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?

Accepted Answer

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.

Question 11

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?

Accepted Answer

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.

Quiz 25: Nursing Management: Burns