Question 1

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

Accepted Answer

The patient should be placed in Fowler's position to make ventilation easier. Pillows should not be used under the head of a patient with neck burns, and the arms and hands should be extended to avoid flexure contractures, even though this position will not be as comfortable for the patient.

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.

Accepted Answer

Half of the fluid replacement using the Parkland formula is administered in the first 8 hours and the other half over the next 16 hours. In this case, the patient should receive half of the initial rate, or 525 ml/hr.

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

Accepted Answer

Use of gowns, caps, masks, and gloves during all patient care will decrease the possibility of wound contamination for a patient whose burns are not covered. Restricting visitors is not necessary and will have adverse psychosocial consequences for the patient. Tap water is used during hydrotherapy, and hydrotherapy tanks are not usually used in burn care because of the risk of cross-contamination. Systemic antibiotics are not well absorbed into deep burns because of the lack of circulation.

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

Accepted Answer

The patient's lab data show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Documentation and continuing to monitor are inadequate responses to the data. Since the hematocrit and hemoglobin are elevated, a transfusion is inappropriate.

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

Accepted Answer

The erythema, swelling, and blisters point to a deep partial-thickness burn. With full-thickness skin destruction, the appearance is pale and dry or leathery and the area is painless because of the associated nerve destruction. With superficial partial thickness burns, the area is red, but no blisters are present.

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

Accepted Answer

All patients with electrical burns should be considered at risk for cervical spine injury, and assessments of extremity movement will provide baseline data. The other assessment data are also necessary but not as essential as determining cervical spine status.

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

Accepted Answer

The willingness to use strategies to enhance appearance is an indication that the problem has resolved. Expressing concern about the scars indicates a willingness to discuss the scars but does not indicate that the disturbed body image is resolved. Scarring from deep partial-thickness burns is permanent, although some improvement in scar appearance may occur. Avoiding using a pillow will help prevent contractures, but it does not address the problem of disturbed body image.

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?

Accepted Answer

H₂-blockers are given to prevent Curling's ulcer in the patient who has suffered burn injuries. H₂-blockers do not impact on bowel sounds, stool frequency, or appetite.

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

Accepted Answer

Since the etiology of the pain is the patient's lack of knowledge about pain control, teaching the patient about how to use adjunctive methods is an appropriate intervention. The other nursing actions may also be used to reduce pain but do not require any behavior change by the patient.

Question 10

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

Accepted Answer

Because medications administered by the oral or IM routes will not be rapidly effective, the nurse should administer medications IV. IV medications are rapidly metabolized, and frequent administration may be necessary. The dosage is not determined by the route, but by its effectiveness. The ease with which respiratory depression can be corrected is not a factor in choosing the route for medication administration in a burn patient.

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?

Accepted Answer

The patient's history and skin color suggest carbon monoxide poisoning, which should be treated by rapidly starting oxygen at 100%. The other actions can be taken after the actions to correct gas exchange.

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

Accepted Answer

At the end of the emergent phase, capillary permeability normalizes and the patient begins to diurese large amounts of urine with a low specific gravity. Although this may occur at about 48 hours, it may be longer in some patients. Blisters and edema begin to resolve, but this process requires more time. White blood cells may increase or decrease based on the patient's immune status and any infectious processes.

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

Accepted Answer

The patient with burns of the face and neck and with decreased breath sounds will require intubation and ventilatory assistance, and the health care provider should be notified so that this can be rapidly accomplished. Placing the patient in a more upright position or having the patient cough will not address the problem of airway edema. Continuing to monitor is inappropriate because immediate action should occur.

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

Accepted Answer

Enteral feedings can usually be initiated during the emergent phase at low rates and increased over 24 to 48 hours to the goal rate. During the emergent phase, the patient will be unable to eat enough calories to meet nutritional needs and may have a paralytic ileus that prevents adequate nutrient absorption. Vitamins and minerals may be administered during the emergent phase, but these will not assist in meeting the patient's caloric needs. Parenteral nutrition increases the infection risk, does not help preserve gastrointestinal function, and is not routinely used in burn patients.

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

Accepted Answer

With chemical burns, the initial action is to remove the chemical from contact with the skin as quickly as possible. Covering the affected area or placing cool compresses on the area will leave the chemical in contact with the skin. Application of an alkaline solution is not recommended.

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?

Accepted Answer

Hyperkalemia can lead to fatal bradycardias and indicates that the patient requires cardiac monitoring and immediate treatment to lower the potassium level. The other laboratory values are also abnormal and require changes in treatment, but they are not as immediately life-threatening as the elevated potassium level.

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?

Accepted Answer

An RN from a medical unit would be familiar with malnutrition and with administration and evaluation of response to enteral feedings and PN. The other patients require burn assessment and care that is more appropriate for staff who regularly care for burned patients.

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

Accepted Answer

The decrease in pulses in a patient with circumferential burns indicates decreased circulation to the arms and the need for escharotomy. Increasing the IV rate may increase the blood flow to the arms slightly, but it will not address the cause of the decreased circulation. Passive ROM will not improve circulation to the arms. Elevating the arms on pillows will decrease circulation.

Question 19

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

Accepted Answer

When fluid intake is adequate, the urine output will be at least 30 to 50 ml/hr. The patient's weight and ratio of intake to output are not useful in this situation because of the effects of third spacing and evaporative fluid loss. A BP of 90/58 is an indication of hypovolemia in a patient who has had a major burn injury.

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?

Accepted Answer

The urine output should be at least 30 to 50 ml/hour during the emergent phase, when the patient is at great risk for hypovolemic shock. The nurse should notify the health care provider because a higher IV rate is needed. BP during the emergent phase should be greater than 90 systolic, and the pulse rate should be less than 120. Serous exudate from the burns is expected during the emergent phase.

Quiz 25: Nursing Management: Burns