Deck 55: Nursing Care of Patients With Burns

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?

A)If the adult is a parent or legal guardian
B)Identification of the substance causing the injury
C)An estimation of the temperature of the burning liquid
D)If any measures were taken at the scene of the accident

Answer 1

Identification of the substance causing the injury

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?

A)Scratching the opposite part of the body will stop the itching.
B)Itching is a problem because it interferes with daily activities.
C)There are pharmacological and nonpharmacological interventions.
D)Some techniques may include massage with a soothing lotion.

Answer 2

Scratching the opposite part of the body will stop the 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? 1.18 percent

A)27 percent
B)36 percent
C)45 percent

Answer 3

36 percent

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?

A)"I am trying to accept that this recovery is full of pain."
B)"I just keep hoping that someday I will be able to be normal."
C)"I can now feed myself and that makes me independent enough."
D)"I am tired of the pain and time that it is taking to move past this."

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)?

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

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?

A)Metabolic demands are increased by injury, interventions, and stress.
B)Enteral feedings will help replace proteins lost from the burn.
C)Nutritional status is maintained until oral intake resumes.
D)Incidence of mortality and infectious morbidity are reduced.

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.)

A)Axillae
B)Buttocks
C)Perineum
D)Forearms
E)Joint areas

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?

A)Reinforcement from people who are close to the patient
B)Professional psychiatric counseling to regain self-esteem
C)Identification of a support group that focuses on victims of crime
D)Information from medical specialists about reconstructive surgery

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?

A)Loss of intravascular fluid
B)Destruction of blood vessels
C)Increased function of platelets
D)Migration of white 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?

A)The normal condition of the patient's skin
B)The nature of the substance causing the burns
C)The patient history of having diabetes mellitus
D)The patient wearing light-weight cotton pajamas

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.)

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

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?

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

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?

A)"This is just a temporary method of covering the burns."
B)"This material is used until my own skin can be grafted."
C)"If these grafts begin to grow, I won't need more surgery."
D)"The purpose of this process is to reduce the risk of infection."

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?

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

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?

A)Checking for the return of distal pulses
B)Padding the bed for copious amounts of drainage
C)Monitoring for unlabored respiratory function
D)Medicating as prescribed for pain management