Deck 25: Nursing Management: Burns

Question 1

When positioning a patient with burns of the head, neck, chest, and right arm and hand, the nurse places the patient

A) laterally with a small pillow under the head and the right arm and hand hyperextended.
B) supine with no pillow and the right arm and hand flexed in a position of comfort and elevated.
C) supine with a small pillow under the head and the right arm and hand elevated on a pillow.
D) in a Fowler's position without a pillow with the right arm and hand extended and elevated on a pillow.

Answer 1

in a Fowler's position without a pillow with the right arm and hand extended and elevated on a pillow.

Question 2

A patient with severe burns has fluid replacement ordered using the Parkland formula. The initial rate of administration is 1050 ml/hr. The nurse would expect that 18 hours after the burn occurred, the rate of the fluid administration should be _____ ml/hr.

A) 263
B) 350
C) 525
D) 1050

Answer 2

525

Question 3

A patient with deep partial-thickness and full-thickness burns of the face and chest has the wounds treated with the open method. The nurse identifies an expected patient outcome of absence of wound infections. An appropriate nursing action to help the patient meet the outcome is to

A) restrict all visitors prevent cross-contamination of wounds.
B) wear gowns, caps, masks, and gloves during all care of the patient.
C) use sterile water for cleansing and debridement in the hydrotherapy tank.
D) administer prophylactic antibiotics to prevent bacterial colonization of wounds.

Answer 3

wear gowns, caps, masks, and gloves during all care of the patient.

Question 4

On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 56%, Hb 17.2 mg/dl (172 g/L), serum K+ 4.8 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Based on these findings, the nurse should plan to

A) document the findings in the patient's record.
B) continue to monitor the laboratory results.
C) increase the rate of the ordered IV solution.
D) type and crossmatch for a blood transfusion.

Question 5

When assessing an emergency department patient who spilled hot oil from a deep-fat fryer on the right leg and foot, the nurse notes that the leg and foot are red, swollen, and covered with large blisters. The patient states that they are very painful. The nurse will document the injury as

A) full-thickness skin destruction.
B) deep partial-thickness skin destruction.
C) superficial partial-thickness skin destruction.
D) deep full-thickness skin destruction.

Question 6

A patient is admitted to the emergency department after suffering an electrical burn from exposure to a high-voltage current. In addition to the burn injuries, the most essential assessment is

A) blood urea nitrogen (BUN) and creatinine levels.
B) pupils' reaction to light.
C) extremity movement.
D) peripheral pulses.

Question 7

A 21-year-old patient who has deep partial-thickness facial and neck burns has a nursing diagnosis of disturbed body image. The nurse evaluates that patient outcomes for this nursing diagnosis are met when the patient

A) starts to use make-up to cover up the scars.
B) expresses concern about the scar appearance.
C) realizes that scarring is temporary.
D) avoids using a pillow under the head.

Question 8

Ranitidine (Zantac) is prescribed for a patient who had extensive burn injuries 5 days ago. Which information will the nurse collect to evaluate the effectiveness of the medication?

A) Bowel sounds
B) Stool frequency
C) Stools for occult blood
D) Percent of meals eaten

Question 9

A patient with burns has the nursing diagnosis of pain related to lack of knowledge of pain-control methods. The most appropriate nursing action for this nursing diagnosis is to

A) request that the health care provider order a patient-controlled analgesia machine for the patient.
B) administer pain medications on a routine basis so that pain does not become out of control.
C) teach the patient how to use ordered analgesics with adjunctive methods such as guided imagery and relaxation.
D) use sedative or amnesic drugs in combination with opioids to reduce the perception of the pain experience.

Question 10

During the early emergent phase of burns, the nurse will anticipate giving opioid analgesics by the IV route so that

A) the medications will be rapidly effective.
B) less frequent administration is needed.
C) larger doses of medications can be given.
D) respiratory depression can be easily treated.

Question 11

A patient who was found unconscious in a burning bedroom and has burns to the lower legs is assessed by the nurse in the emergency department. The nurse notes that the patient's face is bright red. Which of these actions should the nurse take first?

A) Elevate the legs on pillows.
B) Place the patient on 100% O₂ using a non-breather mask.
C) Assess for singed nasal hair and dark oral mucous membranes.
D) Insert 2 large-bore IV lines.

Question 12

The nurse caring for a patient admitted with burns over 30% of the body surface will recognize that the patient has moved from the emergent to the acute phase of the burn injury when

A) the patient has been hospitalized for 48 hours.
B) blisters and edema have subsided.
C) white blood cell levels decrease.
D) the patient has large quantities of pale urine.

Question 13

A patient is admitted to the burn unit with burns of the head, neck, chest, and back following a garage fire. Upon admission to the unit, the nurse auscultates wheezes in the patient's lungs. One hour later, the wheezes cannot be heard, and lung sounds are decreased. The most appropriate action by the nurse is to

A) place the patient in high-Fowler's position.
B) encourage the patient to cough and auscultate the lungs again.
C) document the results and continue to monitor the ventilation.
D) notify the health care provider about the breath sounds.

Question 14

The nurse admitting a patient with an extensive burn injury develops a nursing diagnosis of risk for imbalanced nutrition: less than body requirements related to high caloric needs. The initial action by the nurse should be to

A) encourage an oral intake of at least 5000 kcal per day.
B) administer multiple vitamins and minerals in the IV solution.
C) infuse total parenteral nutrition via a central catheter.
D) insert a feeding tube and give 20 ml/hr enteral feedings.

Question 15

An employee spilled industrial acids on the arms and legs at work. Before transporting the individual to the hospital, the occupational nurse at the facility should

A) cover the affected area with dry, sterile dressings.
B) flush the burned area with large amounts of tap water.
C) place cool compresses on the area of exposure.
D) apply an alkaline solution to the affected area.

Question 16

Which of these laboratory results requires the most rapid action by the nurse who is caring for a patient who suffered a large burn 48 hours ago?

A) Serum sodium, 146 mEq/L
B) BUN 36 mg/dl
C) Serum potassium 6.2 mEq/dl
D) Hct 52%

Question 17

Which of these patients is most appropriate for the burn unit charge nurse to assign to an RN staff nurse who has floated from the hospital medical unit?

A) A 34-year-old patient who has a weight loss of 15% from admission and requires enteral feedings and parenteral nutrition (PN)
B) A 45-year-old patient who has just come back to the unit after having a cultured epithelial autograft to the chest
C) A 60-year-old patient who has twice-daily burn débridements and dressing changes to partial-thickness facial burns
D) A 63-year-old patient who has blebs under an autograft on the thigh and has an order for bleb aspiration

Question 18

A patient with burns of the upper thorax and circumferential burns of both arms develops decreased radial pulses and loss of sensation in the fingers. The most appropriate action by the nurse is to

A) notify the health care provider.
B) increase the IV rate and re-evaluate (ROM) on the patient's arms.
C) elevate the arms on pillows.
Correct

Question 19

The nurse determines that fluid replacement for a patient with major burns is adequate, based on the finding of

A) daily weight unchanged from admission.
B) BP of 90/58.
C) urinary output of 40 ml/hr.
D) total fluid intake equal to urinary output.

Question 20

Six hours after a thermal burn injury involving the anterior and posterior chest and both arms, the nurse obtains all of these data when assessing a patient. Which information is most important to communicate to the health care provider?

A) Blood pressure is 94/46 per arterial line.
B) Cardiac monitor shows a pulse rate of 104.
C) Urine output is 20 to 30 ml per hour.
D) Serous exudate is leaking from the burns.

Question 21

To provide wound care for the patient with deep partial-thickness and full-thickness burns, the nurse plans to

A) apply sterile wet-to-dry dressings to burned areas bid.
B) clean and scrub the wounds twice a week to remove eschar.
C) immerse the patient in a hydrotherapy tank for 30 minutes 4 times daily.
D) shower or bathe the patient daily to remove loose, necrotic skin.

Question 22

The RN observes all of these actions being taken by a staff nurse who has floated to the unit. Which action requires that the RN intervene?

A) The float nurse obtains burn cultures when the patient has a temperature of 95.2° F.
B) The float nurse calls the health care provider for an insulin order when a nondiabetic patient has an elevated serum glucose.
C) The float nurse administers as-needed fentanyl (Sublimaze) IV to a patient 5 minutes before a dressing change.
D) The float nurse lowers room temperature to 76° F during the dressing change of a patient with large burns.

Question 23

A patient with extensive electrical burn injuries is admitted to the emergency department. Which of these health care provider orders should the nurse implement first?

A) Place on cardiac monitor.
B) Start 2 large bore IVs.
C) Assess for pain at contact points.
D) Apply dressings to burned areas.

Question 24

Two weeks after admission for major burns, a patient is continuing to lose weight despite a high-carbohydrate, high-protein diet. The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements. In planning nursing interventions, the best between-meal snack for the patient would be

A) eggnog.
B) bagel.
C) nuts.
D) crackers and cheese.

Question 25

A patient in the acute phase of burn injury requires frequent hydrotherapy sessions for wound débridement. To evaluate for complications of hydrotherapy, the nurse will plan to closely monitor

A) serum sodium level.
B) lung sounds.
C) pulse quality.
D) daily urine output.

Question 26

Which of these nursing actions should be accomplished first for a patient who has suffered a burn injury while working on an electrical power line?

A) Obtain the patient's vital signs.
B) Place a cervical collar on the patient.
C) Assess for the contact points.
D) Place on a cardiac monitor.

Question 27

Which action should the nurse take first when caring for a patient who has just arrived in the emergency department with facial and chest burns caused by a house fire?

A) Ringer's solution
B) Lung sounds
C) Size and depth
D) Ordered opioid

Question 28

A patient who has burns on the back and legs from a house fire has become agitated and restless 9 hours after being admitted to the hospital. Which action should the nurse take first?

A) Administer the ordered morphine sulfate IV.
B) Assess orientation and level of consciousness.
C) Use pulse oximetry to check the oxygen saturation.
D) Stay at the bedside and reassure the patient.