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Nursing Management: BURNS

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Chapter 24: burn management

74 terms Renita_KeithPreview NURS 272 Exam 4 53 terms meardleyPreview EAQs B 38 terms jaym A nurse is caring for a patient with second- and third- degree burns to 50% of the body. The nurse prepares fluid resuscitation based on knowledge of the Parkland (Baxter) formula that includes which recommendation?The total 24-hour fluid requirement should be administered in the first 8 hours.One half of the total 24-hour fluid requirement should be administered in the first 8 hours.One third of the total 24-hour fluid requirement should be administered in the first 4 hours.One half of the total 24-hour fluid requirement should be administered in the first 4 hours.One half of the total 24-hour fluid requirement should be administered in the first

• hours. Correct

The nurse is caring for a patient with superficial partial- thickness burns of the face sustained within the last 12 hours. Upon assessment the nurse would expect to find which manifestation?Blisters Reddening of the skin Destruction of all skin layers Damage to sebaceous glands Reddening of the skin Correct

3.ID: 809645823

The nurse is planning care for a patient with partial- and full-thickness skin destruction related to burn injury of the lower extremities. Which interventions should the nurse expect to include in this patient's care ()? (select all that apply)?Escharotomy Administration of diuretics IV and oral pain medications Daily cleansing and debridement Application of topical antimicrobial agent IV and oral pain medications Correct Daily cleansing and debridement Correct Application of topical antimicrobial agent Correct Escharotomy Correct The nurse is caring for a patient with partial- and full- thickness burns to 65% of the body. When planning nutritional interventions for this patient, what dietary choices should the nurse implement?Full liquids only Whatever the patient requests High-protein and low-sodium foods High-calorie and high-protein foods High-calorie and high-protein foods Correct

5.ID: 809645829

A patient is admitted to the emergency department with first- and second-degree burns after being involved in a house fire. Which assessment findings would alert you to the presence of an inhalation injury? (select all that apply)?Singed nasal hair Generalized pallor Painful swallowing Burns on the upper extremities History of being involved in a large fire History of being involved in a large fire Correct Singed nasal hair Correct Generalized pallor Correct Painful swallowing Correct When caring for a patient with an electrical burn injury, which order from the health care provider should the nurse question?Mannitol 75 gm IV Urine for myoglobulin Lactated Ringer's at 25 mL/hr Sodium bicarbonate 24 mEq every 4 hours Lactated Ringer's at 25 mL/hr Correct Electrical injury puts the patient at risk for myoglobinuria, which can lead to acute renal tubular necrosis (ATN) A patient is admitted with second- and third-degree burns covering the face, entire right upper extremity, and the right anterior trunk area. Using the rule of nines, what should the nurse calculate the extent of these burns as being?18".5'6".5% Correct

An 82-year-old patient is moving into an independent living facility. What is the best advice the nurse can give to the family to help prevent this patient from being accidently burned in her new home?Cook for her.Stop her from smoking.Install tap water anti-scald devices.Be sure she uses an open space heater.Install tap water anti-scald devices. Correct The ambulance reports that they are transporting a patient to the ED who has experienced a full-thickness thermal burn from a grill. What manifestations should the nurse expect?Severe pain, blisters, and blanching with pressure Pain, minimal edema, and blanching with pressure Redness, evidence of inhalation injury, and charred skin No pain, waxy white skin, and no blanching with pressure Correct No pain, waxy white skin, and no blanching with pressure Correct In caring for a patient with burns to the back, the nurse knows that the patient is moving out of the emergent phase of burn injury when what happens?Serum sodium and potassium increase Serum sodium and potassium decrease.Edema and arterial blood gases improve.Diuresis occurs and hematocrit decreases.Diuresis occurs and hematocrit decreases. Correct When teaching the patient about the use of range-of- motion (ROM), what explanations should the nurse give to the patient? (select all that apply)?The exercises are the only way to prevent contractures.Active and passive ROM maintain function of body parts.ROM will show the patient that movement is still possible.Movement facilitates mobilization of leaked exudates back into the vascular bed.Active and passive ROM can only be done while the dressings are being changed.Active and passive ROM maintain function of body parts. Correct ROM will show the patient that movement is still possible. Correct

12.ID: 809538377

During the care of the patient with a burn in the acute phase, which new interventions should the nurse expect to do after the patient progressed from the emergent phase?Begin IV fluid replacement.Monitor for signs of complications.Assess and manage pain and anxiety.Discuss possible reconstructive surgery.Monitor for signs of complications. Correct

4.ID: 809538380

A patient with a burn inhalation injury is receiving albuterol (Ventolin) for bronchospasm. What is the most important adverse effect of this medication for the nurse to manage?GI distress Tachycardia Restlessness Hypokalemia Tachycardia The patient in the emergent phase of a burn injury is being treated for pain. What medication should the nurse anticipate using for this patient?SQ tetanus toxoid IV morphine sulfate IM hydromorphone (Dilaudid) PO oxycodone and acetaminophen (Percocet) IV morphine sulfate Correct The patient received a cultured epithelial autograft (CEA) to the entire left leg. What should the nurse include in the discharge teaching for this patient?Sit or lay in the position of comfort.Wear a pressure garment for 8 hours each day.Refer the patient to a counselor for psychosocial support.Use the sun to increase the skin color on the healed areas.Refer the patient to a counselor for psychosocial support. Correct The patient in the acute phase of burn care has electrical burns on the left side of her body, type 2 diabetes mellitus, and a serum glucose level of 485 mg/dL. What should be the nurse's priority intervention to prevent a life-threatening complication of hyperglycemia for this burned patient?Replace the blood lost.Maintain a neutral pH.Maintain fluid balance.Replace serum potassium.Maintain fluid balance. Correct