Deck 55: Nursing Care of Patients With Burns
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Deck 55: Nursing Care of Patients With Burns
1
A patient is diagnosed with superficial partial-thickness burns.How many days should the nurse instruct the patient that these burns will need to heal?
A) 1 to 5
B) 7 to 10
C) 14 to 21
D) 28 to 45
A) 1 to 5
B) 7 to 10
C) 14 to 21
D) 28 to 45
7 to 10
2
The nurse is caring for a patient who sustained a partial-thickness burn to the face.Which assessment findings should the nurse expect? (Select all that apply.)
A) Blisters
B) Charred skin
C) White patches
D) Bright red color
E) Leathery character
F) Blanching when touched
A) Blisters
B) Charred skin
C) White patches
D) Bright red color
E) Leathery character
F) Blanching when touched
Blisters
Bright red color
Blanching when touched
Bright red color
Blanching when touched
3
The nurse is caring for a patient 3 days following a split-thickness burn injury from a fire.Which observation indicates that nursing interventions to promote cardiac output have been effective?
A) Blood pressure is 128/66 mmHg.
B) Radial pulses are thready at 112/min.
C) Urine output is 1050 mL in 24 hours.
D) Patient weight is 4 pounds less than admission weight.
A) Blood pressure is 128/66 mmHg.
B) Radial pulses are thready at 112/min.
C) Urine output is 1050 mL in 24 hours.
D) Patient weight is 4 pounds less than admission weight.
Blood pressure is 128/66 mmHg.
4
A victim of a fire in a manufacturing plant is brought to the emergency department.The HCP suspects this victim has sustained an inhalation injury.Which tests should the nurse expect to be prescribed for this patient? (Select all that apply.)
A) Chest x-ray
B) Bronchoscopy
C) Arterial blood gases
D) CT scan of the thorax
E) Carboxyhemoglobin level
A) Chest x-ray
B) Bronchoscopy
C) Arterial blood gases
D) CT scan of the thorax
E) Carboxyhemoglobin level
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5
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 should be 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) Apply neutralizing agent to burn area.
E) Obtain a history of the event and burning agent.
F) Provide copious tepid water lavage for 20 minutes.
A) Apply ice packs to burn sites.
B) Remove all contaminated clothing.
C) Cover the patient with a clean sheet.
D) Apply neutralizing agent to burn area.
E) Obtain a history of the event and burning agent.
F) Provide copious tepid water lavage for 20 minutes.
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6
The nurse is preparing a patient with 46% total body surface area burned for graft placement.Which anatomical locations should 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) Abdomen
F) Joint areas
A) Axillae
B) Buttocks
C) Perineum
D) Forearms
E) Abdomen
F) Joint areas
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7
The nurse is providing wound care to a patient's skin graft donor sites used for burn treatment.For which type of wound is this nurse providing care?
A) Skin tear
B) Full thickness
C) Split thickness
D) Partial thickness
A) Skin tear
B) Full thickness
C) Split thickness
D) Partial thickness
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8
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) PaCO2 is 56 mm Hg.
B) The patient is afebrile.
C) The patient is alert and oriented.
D) Peripheral pulses are present and strong.
A) PaCO2 is 56 mm Hg.
B) The patient is afebrile.
C) The patient is alert and oriented.
D) Peripheral pulses are present and strong.
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9
The nurse is caring for a patient with extensive burns.For which systemic responses to the burn should the nurse monitor the patient? (Select all that apply.)
A) Hypovolemia
B) Peptic ulceration
C) Decreased metabolism
D) Increased platelet function
E) Increased oxygen consumption
F) Depression of immunoglobulins
A) Hypovolemia
B) Peptic ulceration
C) Decreased metabolism
D) Increased platelet function
E) Increased oxygen consumption
F) Depression of immunoglobulins
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10
A patient has burns on both legs and in the genital/perineum area.What is this patient's percentage of burned area?
A) 18%
B) 19%
C) 37%
D) 54%
A) 18%
B) 19%
C) 37%
D) 54%
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11
A patient is having a surgical procedure done to promote peripheral tissue perfusion in an extremity with full-thickness circumferential burns.What term should the nurse use to document this procedure?
A) Excision
B) Skin graft
C) Débridement
D) Escharotomy
A) Excision
B) Skin graft
C) Débridement
D) Escharotomy
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12
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 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
A) Report of increasing pain
B) Temperature 99°F (37.2°C)
C) Serum-filled blister formation
D) Blood pressure 122/74 mm Hg
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13
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%
A) 18%
B) 27%
C) 36%
D) 45%
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14
A patient is admitted to the emergency department with chemical burns to the chest and abdomen.The RN immediately begins a sterile saline lavage.What should the licensed practical nurse (LPN)do to assist during this procedure?
A) Apply a neutralizing agent.
B) Apply ice to the burned area.
C) Remove the patient's clothing.
D) Prepare intravenous morphine for administration by the RN.
A) Apply a neutralizing agent.
B) Apply ice to the burned area.
C) Remove the patient's clothing.
D) Prepare intravenous morphine for administration by the RN.
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15
A patient wants to know how long it will take to know if a skin graft used to cover a burn site is successful.How many days should the nurse explain as needed for graft vascularization to occur?
A) 1 to 2
B) 3 to 5
C) 7 to 9
D) 11 to 13
A) 1 to 2
B) 3 to 5
C) 7 to 9
D) 11 to 13
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16
The nurse is caring for a patient who is receiving 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.After reporting these findings,which order should 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.
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.
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17
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) Increase oral fluids to 3000 mL/day.
B) Notify the registered nurse (RN) or primary care provider.
C) Monitor the patient for further changes in mental status.
D) Administer a prn dose of acetaminophen (Tylenol) for the fever.
A) Increase oral fluids to 3000 mL/day.
B) Notify the registered nurse (RN) or primary care provider.
C) Monitor the patient for further changes in mental status.
D) Administer a prn dose of acetaminophen (Tylenol) for the fever.
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18
A patient with a deep partial thickness burn is prescribed wet to dry gauze dressings.Which type of debridement is the nurse performing with this dressing?
A) Surgical
B) Chemical
C) Mechanical
D) Escharotomy
A) Surgical
B) Chemical
C) Mechanical
D) Escharotomy
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19
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 the nurse perform first?
A) Ensure an open airway.
B) Cover the burns with sterile dressings.
C) Wash the burn gently with dilute antiseptic.
D) Pour cool, clean water over the burned areas.
A) Ensure an open airway.
B) Cover the burns with sterile dressings.
C) Wash the burn gently with dilute antiseptic.
D) Pour cool, clean water over the burned areas.
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20
The nurse notes that a patient with full thickness burns has an increase in hematocrit level.What should 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
A) Loss of intravascular fluid
B) Destruction of blood vessels
C) Increased function of platelets
D) Migration of white blood cells
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21
The nurse is preparing to apply dressings to a patient's partial-thickness burn wounds.What should the nurse keep in mind when applying these dressings? (Select all that apply.)
A) Wrap digits as one dressing.
B) Elevate affected extremities.
C) Limit the amount of dressing bulk.
D) Wrap extremities from distal to proximal.
E) Double the estimated size of dressing material.
A) Wrap digits as one dressing.
B) Elevate affected extremities.
C) Limit the amount of dressing bulk.
D) Wrap extremities from distal to proximal.
E) Double the estimated size of dressing material.
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22
A patient with a partial thickness burn wound is prescribed synthetic dressings.What should the nurse explain to the patient about this type of dressing? (Select all that apply.)
A) Easier to store
B) Cost less to use
C) Readily available
D) Come in various shapes
E) Contain antimicrobial substances
A) Easier to store
B) Cost less to use
C) Readily available
D) Come in various shapes
E) Contain antimicrobial substances
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