Deck 27: Nursing Management: Burns

Question 1

A patient is admitted to the burn unit with burns on his head and neck,chest and back,and left arm and hand following an explosion and fire in his garage.On his 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.What is the most appropriate nursing action at this time?

A) Place the patient in the high-Fowler's position.
B) Encourage the patient to cough,and auscultate the lungs again.
C) Document the results,and continue to monitor the patient's progress.
D) Anticipate the need for endotracheal intubation,and notify the physician.

Answer 1

Anticipate the need for endotracheal intubation,and notify the physician.

Question 2

A young woman spilled hot oil from a deep-fat fryer on her right lower leg and foot.Her leg and foot are red and swollen and covered with large blisters.She states that they are very painful.According to burn classification systems,how should the nurse document the burn?

A) Full-thickness skin destruction
B) Deep,partial-thickness skin destruction
C) Superficial,partial-thickness skin destruction
D) Third degree,with partial-thickness skin destruction

Answer 2

Deep,partial-thickness skin destruction

Question 3

Which is an appropriate intervention during the emergent phase of a patient with extensive burns to address the nursing diagnosis of imbalanced nutrition?

A) An oral intake of 5000 kcal/day
B) Intravenous administration of multivitamins and minerals
C) Administration of total parenteral nutrition via a central catheter
D) Continuous enteral feeding via a feeding tube positioned in the duodenum

Answer 3

Continuous enteral feeding via a feeding tube positioned in the duodenum

Question 4

A patient with burns has the nursing diagnosis of pain related to lack of knowledge of pain control methods.What is an appropriate nursing intervention for this problem?

A) Request that the physician order a patient-controlled analgesia machine for the patient.
B) Administer pain medications on a routine basis so that the 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 narcotics to reduce the perception of the pain experience.

Question 5

To prevent hypothermia,what is the maximum amount of time a large burn should be cooled?

A) 2 to 3 minutes
B) 5 minutes
C) 10 minutes
D) 20 minutes

Question 6

During the emergent phase of burn injury,the nurse assesses for the presence of hypovolemia.What does the nurse understand is the primary cause of hypovolemia in burn victims?

A) Major blood loss from injured tissue
B) Evaporation of fluid from denuded body surfaces
C) Capillary permeability that causes fluid shift to the interstitium
D) Third spacing of fluid from the interstitial space into fluid-filled vesicles

Question 7

When does the nurse recognize that the patient with a burn injury moves from the emergent phase to the acute phase?

A) When inflammatory symptoms subside
B) When the burn area is completely covered
C) When granulation tissue forms in the wounds
D) When diuresis occurs with low urine specific gravity

Question 8

The nurse determines that fluid replacement for a patient with major electrical burns is adequate based on which of the following findings?

A) A stable weight
B) A blood pressure of 90/58 mm Hg
C) A urinary output of 80 mL/hour
D) An intake equal to urinary output

Question 9

A common nursing diagnosis for the patient with burns is situational low self-esteem.When would the nurse evaluate that patient outcomes for this nursing diagnosis are met?

A) When the patient sets realistic goals regarding future lifestyle
B) When the patient accepts the need for psychiatric intervention
C) When the patient is interested in learning to care for wounds at home
D) When the patient expresses that the effects of the burn are not important

Question 10

Which of the following laboratory results should the nurse monitor closely in the patient during the acute phase of burn injury?

A) Hematocrit and serum sodium
B) Serum albumin and hematocrit
C) Serum potassium and hematocrit
D) Serum sodium and serum potassium

Question 11

A patient is to undergo skin grafting with the use of cultured epithelial autografts (CEAs)as skin replacement for full-thickness burns.The nurse explains to the patient that this treatment involves which of the following?

A) Shaving a split-thickness layer of the patient's skin from an unburned area to apply over burn wounds
B) Growing small specimens of the patient's skin in sheets,which are grafted as permanent skin coverage
C) Cultivating skin from a cadaver with epidermal growth factor to temporarily cover burn wounds for 1 to 2 weeks
D) Exposing animal skin to growth factors that stimulate its proliferation and decrease antigenicity for permanent skin coverage of the wound

Question 12

To prevent contractures in a patient with burns of the head,neck,chest,and right arm and hand,how should the nurse position the patient?

A) Supine with a pillow under the head and the right arm and hand elevated on a pillow
B) In a Fowler's position without a pillow with the right arm and hand extended and elevated on a pillow
C) Laterally on the left side with a small pillow under the head and the right arm and hand hyperextended
D) Supine without a pillow and with the right arm and hand flexed in a position of comfort and elevated on pillows

Question 13

An employee spilled industrial acids on his arms and legs at work.What is the appropriate action by the occupational nurse at the facility?

A) Apply cool compresses to the area of exposure.
B) Apply an alkaline solution to the affected area.
C) Cover the affected area with dry,sterile dressings.
D) Flush the substance with large amounts of tap water.

Question 14

Ranitidine (Zantac)is prescribed for a patient with major burns.In teaching the patient about the drug's purpose,the nurse should explain that it is used to prevent which of the following?

A) Diarrhea
B) Constipation
C) Adynamic ileus
D) Curling's ulcer

Question 15

A patient with burns on the upper thorax and circumferential burns on both arms develops decreased radial pulses and loss of sensation in the fingers.What is the most appropriate nursing action?

A) Notify the physician because an escharotomy is indicated.
B) Increase the rate of fluid administration to prevent sludging.
C) Put the patient's arms through passive range-of-motion exercises.
D) Elevate the extremities on pillows and re-evaluate the patient in 30 minutes.

Question 16

Which of the following burn victims should the nurse assess for carbon monoxide inhalation?

A) Was found unconscious in a burning building
B) Has facial burns,hoarseness,and sooty sputum
C) Inhaled a large amount of steam released by a radiator
D) Was burned in a charcoal grill fire ignited with gasoline

Question 17

A patient with severe burns has fluid replacement ordered using the Parkland formula.The initial rate of administration is 1050 mL/hour.What should the nurse expect the rate of fluid administration to be 18 hours after the burn occurred?

A) 263 mL/hour
B) 350 mL/hour
C) 525 mL/hour
D) 1050 mL/hour

Question 18

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 a nursing diagnosis of risk for infection and an expected patient outcome of absence of wound infections.What is an appropriate nursing intervention to help the patient meet the expected outcome?

A) Restrict all visitors to 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 broad-spectrum antibiotics to prevent bacterial colonization of wounds.

Question 19

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 nurse should initially assess for the presence of what?

A) Renal failure
B) Cerebral edema
C) Spinal fractures
D) Metabolic alkalosis

Question 20

During the early emergent phase of burns,the nurse understands that analgesics should be given intravenously for which of the following reasons?

A) Absorption of oral or intramuscular drugs is diminished because of impaired circulation.
B) Analgesics do not need to be administered as frequently when they are given intravenously.
C) Larger doses of narcotics can be given when administered intravenously than when given intramuscularly.
D) Respiratory depression is easier to diagnose and treat when narcotics are administered intravenously.

Question 21

Which of the following is considered the most accurate guide for determining the total body surface area affected by a burn?

A) Rule-of-nines chart
B) Lund-Browder chart
C) Sage burn diagram
D) Burn injury depth classification

Question 22

With chemical burns,the nurse knows that tissue destruction can continue for up to how many hours after the initial burn?

A) 12
B) 24
C) 48
D) 72

Question 23

Which of the following injuries is most often chemically produced?

A) Carbon monoxide poisoning
B) Inhalation injury below the glottis
C) Alkali burn
D) Circumferential chest burn