Deck 55: Nursing Care of Patients With Burns

Question 1

The nurse is caring for a patient 3 days following a split-thickness burn injury from a fire. Which of the following best indicates that nursing interventions to promote adequate cardiac output have been effective?

A)Urine output is 1,050 mL in 24 hours.
B)Radial pulses are thready at 112/min.
C)Blood pressure is 128/66 mmHg.
D)Patient weight is 4 pounds less than admission weight.Multiple Response
Identify one or more choices that best complete the statement or answer the question.

Answer 1

Blood pressure is 128/66 mmHg.

Question 2

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

A)Obtain a history of the event and burning agent.
B)Cover the patient with a clean sheet.
C)Apply ice packs to burn sites.
D)Provide copious tepid water lavage for 20 minutes.
E)Remove all contaminated clothing.
F)Apply neutralizing agent to burn area.

Answer 2

Obtain a history of the event and burning agent.
Cover the patient with a clean sheet.
Provide copious tepid water lavage for 20 minutes.
Remove all contaminated clothing.

Question 3

The nurse is caring 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?

A)18%
B)27%
C)36%
D)45%

Answer 3

36%

Question 4

The nurse is caring for a patient who is undergoing fluid replacement after being burned on 37% of the body. Nursing assessment reveals a blood pressure of 80/60 mm Hg, heart rate of 120 beats/min, and urine output of 10 mL over the past hour. The nurse reports assessment findings to the physician and anticipates which of the following orders?

A)Increase the amount of IV fluid administered per hour.
B)Decrease the amount of IV fluid administered per hour.
C)Change the IV fluid to dextrose and water.
D)Discontinue the IV fluid infusion.

Question 5

The nurse is caring for a patient admitted to the burn unit with burns to 45% 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. What should the nurse do first?

A)Monitor the patient for further changes in mental status.
B)Administer a prn dose of acetaminophen (Tylenol) for the fever.
C)Increase oral fluids to 3,000 mL/day.
D)Notify the RN or physician.

Question 6

Which of the following anatomical locations tend to have a lower rate of graft success than other areas of the body? (Select all that apply.?

A)Buttocks
B)Forearms
C)Joint areas
D)Axillae
E)Perineum
F)Abdomen
Completion
Complete each statement.

Question 7

A patient is having a surgical procedure done to relieve alteration in peripheral tissue perfusion in an extremity with full-thickness circumferential burns. What term describes this procedure?

A)Excision
B)Skin graft
C)Débridement
D)Escharotomy

Question 8

Superficial partial-thickness burns usually require 7 to ________________days to heal.

Question 9

The nurse is caring for a patient who sustained a partial-thickness burn to the face. Which of the following assessment findings would the nurse expect? (Select all that apply.?

A)Charred skin
B)Leathery character
C)Blisters
D)White patches
E)Bright red color
F)Blanching when touched

Question 10

Which of the following type of wound best describes a skin graft donor site?

A)Skin tear
B)Partial thickness
C)Full thickness
D)Split thickness

Question 11

Graft success, or vascularization, is usually complete within 3 to ________________days following the procedure.

Question 12

The nurse is caring for a patient with extensive burns. Which of the following are systemic responses to a burn that the nurse should be aware of? (Select all that apply.?

A)Decreased metabolism
B)Hypovolemia
C)Increased platelet function
D)Increased oxygen consumption
E)Depression of immunoglobulins
F)Peptic ulceration

Question 13

The nurse is caring for a patient in the initial phase 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). Which new assessment finding should be immediately communicated to the RN or physician?

A)Blood pressure 122/74 mm Hg
B)Temperature 99°F (37.2°C)
C)Report of increasing pain
D)Serum-filled blister formation

Question 14

A patient who has burns on both legs and in the genital/perineum area has burns over approximately ____________________% of the body.

Question 15

The nurse is at the scene of a fire caring for a patient with a thermal burn on the face, chest, and abdomen. What action should receive first priority?

A)Pour cool, clean water over the burned areas.
B)Cover the burns with sterile dressings.
C)Wash the burn gently with dilute antiseptic.
D)Ensure an open airway.

Question 16

The nurse is caring for a patient who is 2 days post-inhalation burn injury from a house fire. Which outcome best indicates that nursing interventions for impaired gas exchange have been effective?

A)Peripheral pulses are present and strong.
B)PaCO₂ is 56 mm Hg.
C)The patient is alert and oriented.
D)The patient is afebrile.

Question 17

A patient is admitted to the emergency department with chemical burns to the chest and abdomen. The RN immediately begins lavaging the area with sterile saline. What should the LPN do to assist during this procedure?

A)Prepare intravenous morphine for administration by the RN.
B)Apply ice to the burned area.
C)Remove the patient's clothing.
D)Apply a neutralizing agent.