Deck 61: Caring for the Patient With Burn Injuries

Question 1

During the immediate postburn period, the nurse conducts a rapid but thorough assessment. Which finding indicates a potential complication?

A) Coughing
B) Presence of eschar
C) Urine output of 30 mL in the hour since the burn occurred
D) Edema in the burned area

Answer 1

Coughing

Question 2

The nurse is teaching a patient about the need for continued stretching exercises after discharge from burn treatment. The nurse evaluates that the patient understands what is necessary when the patient makes which statement?

A) "If I stretch, I don't need to use my splints."
B) "If the scar blanches, it means I have stretched too far."
C) "A progressive exercise program will not increase my overall stamina."
D) "Stretching exercises help increase the range of motion in my burned arm."

Answer 2

"Stretching exercises help increase the range of motion in my burned arm."

Question 3

Escharotomies have been performed on a patient's arms because of circumferential burn injuries. What is the nurse's highest assessment priority?

A) Circulation in the extremity distal to the escharotomy
B) Formation of contractures
C) Wound infection in the escharotomy site
D) Ability to perform range-of-motion exercises

Answer 3

Circulation in the extremity distal to the escharotomy

Question 4

A patient sustained a radiation injury in an accident at a nuclear power plant. Which assessment questions would the nurse ask to determine the depth of this injury? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) "How close were you to the source?"
B) "How long were you exposed to the source?"
C) "How hot did the source get?"
D) "Was steam produced during the accident?"
E) "Where did the radiation enter and exit your body?"

Question 5

Which patient care goals does the nurse prioritize during the acute phase of burn treatment? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) Preventing infection
B) Preventing loss of body heat through the wounds
C) Securing and maintaining the airway
D) Splinting, positioning, and exercising affected joints
E) Providing for patient comfort

Question 6

A patient is scheduled to receive a meshed skin graft to begin closing a major burn injury. How would the nurse explain the rationale for using a meshed graft?

A) "Meshing allows the graft to cover a larger area."
B) "Meshing improves the look of the healed wound."
C) "Meshing increases the thickness of the graft."
D) "Meshing holds the serous fluid next to the wound."

Question 7

The nurse is admitting a 25-year-old patient to the emergency department with partial-thickness injuries over 20% of the total body surface area, involving both lower legs. According to American Burn Association ABA) guidelines, the nurse would classify this as which level of burn?

A) Minor
B) Major
C) Moderate
D) Severe

Question 8

During the acute period of burn care, a focus of care is to promote healing of full-thickness burn wounds. Which nursing interventions are necessary before this healing can begin?

A) Administration of diuretics to reduce edema in the wound bed
B) Pharmacologic and nonpharmacologic methods to achieve pain-free status
C) Debridement and cleansing to rid the wound bed of eschar
D) Nutritional support to return the patient to preburn weight

Question 9

The nurse is preparing a patient for discharge from the hospital following a major burn injury. The nurse would consider which pathophysiology when developing a plan for the patient's nutrition?

A) The hypermetabolic state is only present in the emergency and acute phases of burn care.
B) The hypermetabolic state continues until all the wounds are healed.
C) The major dietary need after discharge is additional oral fluids.
D) The calorie intake should be decreased so the patient does not stress new tissue with weight gain.

Question 10

The nurse would anticipate which laboratory result drawn 10 hours after a patient experienced a major burn injury?

A) Potassium level of 3.0 mEq/L
B) Platelets 450,000 uL
C) Hematocrit of 48%
D) Sodium 138 mEq/L

Question 11

The nurse has admitted a patient who sustained a partial-thickness burn injury of 28% of total body surface area TBSA) and a full-thickness injury of 30% of TBSA. Which American Burn Association ABA) classification would the nurse assign to this injury?

A) Moderate
B) Major
C) Superficial
D) Minor

Question 12

A patient has sustained a burn injury to the anterior chest and neck and the right shoulder, arm, and hand. How should the nurse position this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) Extend the arm 90 degrees from the body.
B) Position the arm slightly in front of the midaxillary line.
C) Extend the elbow with the palm of the hand downward.
D) Extend the wrist.
E) Use a pillow to flex the neck.

Question 13

The nurse is caring for a patient who was overexposed to radiation during cancer treatment. The nurse plans care with the knowledge that which cells are most susceptible to this type of radiation injury? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) Skin cells
B) Gastrointestinal tract cells
C) Bone marrow cells
D) Kidney cells
E) Muscle cells

Question 14

Surrounding tissue destroyed by burn is an area identified as the zone of stasis. Which nursing interventions are designed to protect this zone from further damage? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) Strict adherence to infection control measures
B) Elevation of the burned area
C) Early focus on feeding the patient
D) Managing fluid resuscitation
E) Administration of medications to prevent myoglobin release from cells

Question 15

The nurse manager of a burn unit is conducting education for newly hired nurses. What factors would the manager point to as reducing the rate of survival among burn patients? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) History of substance abuse
B) Endocrine diseases
C) Renal disease
D) Cardiac disease
E) Previous burn injury

Question 16

Which information will the nurse collect to assist in the classification of a burn injury as minor, moderate, or major? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) Location of the burns on the body
B) The history of the event and location where the injury occurred
C) Any concurrent injuries
D) The time the injury occurred
E) The causative agent

Question 17

Which grief reactions would the nurse discuss with a patient who is being discharged from the hospital after treatment for major burn injury? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) Separation from home and family
B) Potential change in vocation
C) Change in family role patterns
D) Body image change
E) Loss of physical functioning

Question 18

A patient who sustained a burn injury over 65% of the body is in the acute phase of care. The patient's preburn weight was 165 pounds. The nurse would work with the patient to achieve intake of ________ calories each day.

Question 19

The nurse is admitting a 50-year-old female who was involved in a car accident and whose only injuries were burns over 50% of her body. Identify the highest-priority nursing diagnosis for this patient.

A) Acute Pain
B) Coping: Family, Compromised
C) Disturbed Body Image
D) Deficient Fluid Volume

Question 20

The mortality rate for burns is highest in the very young and in the elderly population. What factors put the very young at a higher risk? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) The very young have a greater proportion of body surface area per amount of body mass, resulting in a higher risk for fluid-volume loss.
B) The very young tend to heal more slowly.
C) Infants and young children have an immature immune system with a weak antibody response.
D) The very young have a higher risk for the development of hypovolemic shock.
E) In the very young, burns tend to exacerbate previous medical problems.

Question 21

A nurse is teaching mothers of preschoolers about how to prevent burn injuries. Which information should the nurse include in this teaching? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) Set home hot water heaters at 130°F.
B) Run cold water in the bathtub before adding hot water.
C) Check the temperature of children's baths with the hand before putting the child in the bathtub.
D) Cook on front burners with the pot handle turned to the rear.
E) Place hot items in the middle of the table during meals.

Question 22

A patient sustained a serious electrical burn when he stepped on a downed power line. The nurse would assess for which injuries? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) Fractures in the arms or legs
B) Cardiac dysrhythmia
C) Vision changes
D) Sooty sputum
E) Extensive partial-thickness burns

Question 23

The patient is scheduled for a heterograft to cover a burn wound. How would the nurse explain the source of this graft?

A) "This graft is made from pigskin."
B) "This graft is from a living donor."
C) "This is a cadaver graft."
D) "This graft will be taken from a nonburned area on your body."

Question 24

The nurse is monitoring for development of renal failure in a patient who sustained a moderate burn injury. Which laboratory results would be cause for concern? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) BUN of 40 mg/dL
B) Creatinine of 1.9 mg/dL
C) Total protein of 5.8 g/dL
D) Creatine kinase of 350 U/L
E) Urine specific gravity of 1.020

Question 25

What factor would the nurse evaluate as putting the patient at increased risk for converting a partial-thickness burn injury to a full-thickness injury?

A) The patient develops a wound infection.
B) Assessment of the lungs indicates fluid overload.
C) The patient develops pneumonia.
D) The patient's kidney function is compromised.

Question 26

The nurse is estimating the extent of burns on an adult patient just admitted to the emergency department. The patient has burns on both arms, the anterior trunk, and the right leg. The nurse estimates that _______ % of total body surface area is involved.

Question 27

Which teaching would the nurse provide to the patient prescribed a pressure garment?

A) Wear the garment during daytime hours.
B) Order two garments so one will always be clean.
C) The garment should feel snug but not tight.
D) The patient should plan on wearing the garment for 4 to 6 weeks.

Question 28

A patient has been brought to the emergency department by ambulance after sustaining major burns in a house fire. The nurse would anticipate that which therapies have been initiated? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) Jewelry has been removed.
B) Ice bags have been applied to burned areas.
C) The burn has been covered with a clean sheet.
D) Tetanus prophylaxis status has been determined.
E) Burn ointment has been applied to all partial-thickness burns.

Question 29

Which intervention should the nurse plan for a patient who has a sheet skin graft covering a burn on the forearm?

A) Scrub the graft site with mild soap and water twice daily.
B) Perform range-of-motion exercises twice each shift.
C) Use aseptic technique for all contact with the graft.
D) Lift the edges of the graft twice each shift to allow fluid to escape.

Question 30

The nurse explains to a family that it is not possible to determine the extent of a patient's burns after an accidental electrocution. What rationale does the nurse provide for this statement? Note: Credit will be given only if all correct choices and no incorrect choices are selected.

A) Much of the damage done by electrical burns is beneath the surface.
B) The temperature of electrical energy can exceed 180°F.
C) The injury that is initiated by electrical energy does not stop when the current is interrupted.
D) The energy causing the burn affects rapidly dividing cells, which makes damage variable.
E) Electrical burns cause the same tissue response as alkali chemicals.

Question 31

A patient has sustained a moderate burn injury and requires pain management. Which medication prescription should the emergency department nurse implement?

A) Morphine sulfate 4 mg IV every 2 hours
B) Fentanyl 50 mcg IM every 2 hours
C) Codeine 30 mg PO every 3 hours
D) Ibuprofen 800 mg PO every 6 hours

Question 32

A patient is severely burned over the neck, chest, both arms, and both legs. How should the nurse facilitate fluid resuscitation of this patient?

A) Defer placement of an IV line until the physician can place a central line.
B) Carefully assess the arms and legs for nonburned venous access.
C) Start a small-bore IV catheter in a nonburned area of the hand.
D) Start large-bore IV catheters through burned areas.

Question 33

Which interventions would the nurse perform to help prevent bacterial translocation in a patient who has suffered a severe burn injury? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) Administer glutamine as ordered.
B) Administer enteral feedings as ordered.
C) Administer potassium as ordered.
D) Monitor arterial blood gases.
E) Monitor creatinine.

Question 34

A patient who weighs 132 pounds sustained a burn injury and is receiving fluid resuscitation. The nurse would evaluate adequate hydration if the patient is producing at least ________ mL of urine each hour.

Question 35

An adult patient who weighs 220 pounds has been burned over 70% of the body. Using the Parkland/Baxter formula, the nurse would anticipate administering ______ mL of fluid in the second 8 hours after the patient was burned.