Deck 17: Nursing Care of Patients with Burns

Question 1

A nurse sees a patient get struck by lightning during a thunder storm on a golf course. What should be the FIRST action by the nurse?

A)Check breathing and circulation.
B)Look for entrance and exit wounds.
C)Cover the patient to prevent heat loss.
D)Move the patient indoors to a dry place.
E)Get the patient up off the ground.

Answer 1

Check breathing and circulation.

Question 2

A patient recovering from a major burn injury is complaining of pain. Which of the following medications will be most therapeutic to the patient?

A)morphine 4 mg IV every 5 minutes
B)morphine 10 mg IM ever 3-4 hours
C)meperidine 75 mg IM every 3-4 hours
D)meperidine 50 mg PO every 3-4 hours
E)fentanyl citrate (Duragesic) 75 mcg patch every 3 days

Answer 2

morphine 4 mg IV every 5 minutes

Question 3

When evaluating the laboratory values of the burn-injured patient, which of the following can be anticipated?

A)decreased hemoglobin and elevated hematocrit levels
B)elevated hemoglobin and elevated hematocrit levels
C)elevated hemoglobin and decreased hematocrit levels
D)decreased hemoglobin and decreased hematocrit levels
E)hemoglobin and hematocrit levels within normal ranges

Answer 3

decreased hemoglobin and elevated hematocrit levels

Question 4

A patient comes into the emergency department with a chemical burn from contact with lye.Assessment and treatment of this patient will be based on what knowledge regarding this type of burn? Select all that apply.

A)This is an alkali burn.
B)This type of burn tends to be deeper.
C)This is an acid burn.
D)This type of burn will be easier to neutralize.
E)This type of burn tends to be more superficial.

Question 5

A patient is being discharged after treatment for a scald burn that caused a superficial burn over one hand and a superficial partial-thickness burn on several fingers. What should be included in this patient's discharge instructions? Select all that apply.

A)Report any fever to your healthcare provider.
B)Report development of purulent drainage to your healthcare provider.
C)Use only sterile dressings on the fingers.
D)Cleanse the areas every hour with alcohol to prevent infection.
E)Apply the topical antimicrobial agent as instructed.

Question 6

A patient receiving treatment for severe burns over more than half of his body has an indwelling urinary catheter. When evaluating the patient's intake and output, which of the following should be taken into consideration?

A)The amount of urine will be reduced in the first 24-48 hours, and will then increase.
B)The amount of urine output will be greatest in the first 24 hours after the burn injury.
C)The amount of urine will be reduced during the first eight hours of the burn injury and will then increase as the diuresis begins.
D)The amount of urine will be elevated due to the amount of intravenous fluids administered during the initial phases of treatment.
E)The amount of urine is expected to be decreased for three to five days.

Question 7

A patient is scheduled for surgery to graft a burn injury on the arm. Which of the following statements should the nurse include when instructing the patient prior to the procedure?

A)"You will begin to perform exercises to promote flexibility and reduce contractures after five days."
B)"You will need to report any itching, as it might signal infection."
C)"Performing the procedure near the end of the hospitalization will reduce the incidence of infection and improve success of the procedure."
D)"The procedure will be performed in your room."
E)"You will need to be in protective isolation for several weeks after the graft is performed."

Question 8

In order for the nurse to correctly classify a burn injury, which of the following does the nurse need to assess? Select all that apply.

A)the depth of the burn
B)extent of burns on the body
C)the causative agent and the duration of exposure.
D)location of burns on the body
E)the time that the burn occurred

Question 9

A patient has experienced a burn injury. Which of the following interventions by the nurse is of the highest priority at this time?

A)determination of the type of burn injury
B)determination of the types of home remedies attempted prior to the patient's coming to the hospital
C)assessment of past medical history
D)determination of body weight
E)determination of nutritional status

Question 10

A patient arrives at the emergency department with an electrical burn. What assessment Select all that apply.

A)What type of current was involved?
B)How long was the patient in contact with the current?
C)How much voltage was involved?
D)Where was the patient when the burn occurred?
E)What was the point of contact with the current?

Question 11

A 70-year-old patient has experienced a sunburn over much of the body. What self-care technique is MOST important to emphasize to an older adult in dealing with the effects of the sunburn?

A)increasing fluid intake
B)applying mild lotions
C)taking mild analgesics
D)maintaining warmth
E)using sunscreen

Question 12

A patient has a scald burn on the arm that is bright red, moist, and has several blisters. The nurse would classify this burn as which of the following? Select all that apply.

A)a superficial partial-thickness burn
B)a thermal burn
C)a superficial burn
D)a deep partial-thickness burn
E)a full-thickness burn

Question 13

A patient has sustained a partial-thickness injury of 28% of total body surface area (TBSA) and full-thickness injury of 30% or greater of TBSA. How should the nurse classify this burn injury?

A)major
B)moderate
C)minor
D)superficial
E)intermediate

Question 14

A nurse is teaching a class of older adults at a senior center about household cleaning agents that may cause burns. Which agents should be included in these instructions? Select all that apply.

A)drain cleaners
B)household ammonia
C)oven cleaner
D)toiler bowl cleaner
E)lemon oil furniture polish

Question 15

The nurse is reviewing the results of laboratory tests to assess the renal status of a patient who experienced a major burn event on 45% of the body 24 hours ago. Which of the following results would the nurse expect to see? Select all that apply.

A)glomerular filtration rate (GFR) reduced
B)specific gravity elevated
C)creatinine clearance reduced
D)BUN reduced
E)uric acid decreased

Question 16

A 25-year-old patient is admitted with partial-thickness injuries over 20% of the total body surface area involving both lower legs. The nurse would classify this injury as being which of the following?

A)a moderate burn
B)a minor burn
C)a major burn
D)a severe burn
E)an intermediate burn

Question 17

A patient, experiencing a burn that is pale and waxy with large flat blisters, asks the nurse about the severity of the burn and how long it will take to heal. With which of the following should the nurse respond to this patient?

A)The wound is a deep partial-thickness burn, and will take more than three weeks to heal.
B)The wound is a partial-thickness burn, and could take up to two weeks to heal.
C)The wound is a superficial burn, and will take up to three weeks to heal.
D)The wound is a full-thickness burn and will take one to two weeks to heal.
E)Wound healing is individualized.

Question 18

A patient is being evaluated after experiencing severe burns to his torso and upper extremities. The nurse notes edema at the burned areas. Which of the following best describes the underlying cause for this assessment finding?

A)inability of the damaged capillaries to maintain fluids in the cell walls
B)reduced vascular permeability at the site of the burned area
C)decreased osmotic pressure in the burned tissue
D)increased fluids in the extracellular compartment
E)the IV fluid being administered too quickly

Question 19

When monitoring the vital signs of the patient who has experienced a major burn injury, the nurse assesses a heart rate of 112 and a temperature of 99.9° F. Which of the following best describes the findings?

A)These values are normal for the patient's post-burn injury condition.
B)The patient is demonstrating manifestations consistent with the onset of an infection.
C)The patient is demonstrating manifestations consistent with an electrolyte imbalance.
D)The patient is demonstrating manifestations consistent with renal failure.
E)The patient is demonstrating manifestations of fluid volume overload.

Question 20

A patient is brought to the emergency department with the following burn injuries: a blistered and reddened anterior trunk, reddened lower back, and pale, waxy anterior right arm. Calculate the extent of the burn injury (TBSA) using the rule of nines.

Question 21

A patient with third-degree burns is being treated with high-volume intravenous fluids and has a urine output of 40 cc per hour. The nurse realizes that this urine output

A)is normal for this patient.
B)provides evidence that the patient is dehydrated.
C)provides evidence that the patient is over-hydrated.
D)is indicative of pending renal failure.

Question 22

To stabilize the respiratory system of a patient injured in an explosion the emergency department team must differentiate between upper airway thermal injury and lower airway toxic gas injury. Place an "X" on the structure that divides these two injury zones.

Question 23

Using the rule of nines, the nurse has estimated that the patient has experienced burns over 99% of the total body surface area. Place an "X" on the portion of the body that is most likely unburned in this patient.

Question 24

A patient is coming into the emergency department with third-degree burns over 25% of his body. The nurse should prepare which of the following solutions for intravenous infusion for this patient?

A)warmed lactated Ringer's
B)5% dextrose in water
C)5% dextrose in 0.45 normal saline
D)5% dextrose in normal saline

Question 25

A patient comes into the clinic to be seen for a burn that appears moist with blisters. The nurse realizes that this patient most likely has experienced which of the following?

A)first-degree burn
B)superficial second-degree burn
C)deep second-degree burn
D)third-degree burn

Question 26

Place an "X" over the section of the diagram that represents the depth of a superficial partial-thickness burn. [insert Use figure 16-17 in LeMone 5E. Remove the caption and the labels on the right side (Clark's levels). Retain the left side labels (Skin layers). The Roman numeral labels in the drawing may remain if necessary.]

Question 27

A patient who is being treated with topical mafenide acetate for third-degree burns is demonstrating facial and neck edema. The nurse realizes that this patient most likely

A)is developing a hypersensitivity to the medication.
B)is reacting positively to the medication.
C)needs an increase in dosage of the medication.
D)is not responding to the medication.

Question 28

During the acute phase of burn treatment, important goals of patient care include which of the following? Select all that apply.

A)providing for patient comfort
B)preventing infection
C)providing adequate nutrition for healing to occur
D)splinting, positioning, and exercising affected joints
E)assessing home maintenance management

Question 29

The family of a patient with third-degree burns wants to know why the "scabs are being cut off" of the patient's leg. What is the most appropriate response by the nurse to this family?

A)"The scabs are really old burned tissue and need to be removed to promote healing."
B)"I'll ask the doctor to come and talk with you about the treatment plan."
C)"The patient asked for the scabs to be removed."
D)"The scabs are removed to check for blood flow to the burned area."

Question 30

Following surgical debridement, a patient with third-degree burns does not bleed. The nurse realizes that this patient

A)will need to have the procedure repeated.
B)will no longer need this procedure.
C)will need to be premedicated prior to the next procedure.
D)should have an escharotomy instead.

Question 31

The nurse notes that a patient with third-degree burns is demonstrating a reduction in his serum potassium level. The nurse realizes that this finding is consistent with which of the following?

A)the resolution of burn shock
B)the onset of burn shock
C)the onset of renal failure
D)the onset of liver failure

Question 32

A patient with third-degree burns is prescribed gastrointestinal medication. The primary action of this drug is which of the following?

A)to prevent the onset of a Curling's ulcer
B)to treat a preexisting duodenal ulcer
C)to ensure adequate peristalsis
D)for the antiemetic properties

Question 33

A patient with third-degree burns to her face just learned that she will have extensive scarring once the burn heals. Which of the following nursing diagnoses would be applicable to this patient at this time?

A)Powerlessness
B)Potential for Infection
C)Fluid Volume Deficit
D)Risk for Ineffective Airway Clearance

Question 34

A patient with a burn injury is prescribed silver nitrate. Which of the following nursing interventions should be included for the patient? Select all that apply.

A)Monitor daily weight.
B)Monitor the serum sodium levels.
C)Prepare to change the dressings every two hours.
D)Report black skin discolorations.
E)Push fluid intake.

Question 35

Using the modified Brooke formula, calculate the amount of intravenous solution that will be administered in the first 8 hours for a patient with 40% TBSA and weighs 52 kg.

Question 36

A patient is admitted to the emergency department with deep partial-thickness burns over 35 % of the body. What IV solution will be started initially?

A)warmed lactated Ringer's solution
B)dextrose 5% with saline solution
C)dextrose 5% with water
D)normal saline solution
E)0.45% saline solution

Question 37

A patient with third-degree burns to his right arm is scheduled for passive range of motion to the extremity every two hours. Which of the following should the nurse do prior to this exercise session?

A)Medicate for pain.
B)Empty the patient's in-dwelling catheter collection bag.
C)Change the patient's bed linens.
D)Change the dressing on the burn.

Question 38

The nurse is evaluating the adequacy of a burn-injured patient's nutritional intake. Which of the following laboratory values is the best indicator of a need to adjust the nutritional program?

A)glycosuria
B)creatine phosphokinase (CPK)
C)BUN levels
D)hemoglobin
E)serum sodium levels

Question 39

The burn patient has developed abdominal pain, hematemesis, and melena. The nurse is concerned about possible development of an ulcer. Place an "X" on the portion of the gastrointestinal tract where Curling's ulcer develops.

Question 40

The nurse is providing care to a patient with a third-degree burn on his left thigh and left forearm. During wound care, the nurse applies Elase to the burned areas. Which of the following types ofwound debridement is this nurse using?

A)enzymatic
B)mechanical
C)surgical
D)topical

Question 41

A female patient comes into the clinic complaining of nausea and vomiting after spending the weekend at a seaside resort. Which of the following should be the most important assessment for the nurse?

A)normal rest and sleep pattern
B)typical meal pattern
C)if the patient had to change time zones when traveling to the resort
D)if the patient has been sunburned

Question 42

A patient comes into the physician's office after sustaining chemical burns to the left side of his face and right wrist. The nurse realizes that this patient needs to be treated

A)in the outpatient ambulatory clinic.
B)in the emergency department.
C)in a burn center.
D)in the doctor's office and then at home.