Burns NCLEX style questions with rationales

Burns NCLEX style questions with rationales Leave the first rating Students also studied Terms in this set (11) Science MedicineNursing Save AE3 Exam 2 109 terms AlyssaRay21Preview Chapter 25 Burns NCLEX style quest...22 terms Amanda_Washington7 Preview

Chapter 24: Burns

21 terms autumn_jooyyy Preview Exam 2 143 term Aly When assessing a patient with a partial-thickness burn,

the nurse would expect to find (SATA):

• blisters
• exposed fascia
• exposed muscles
• intact nerve endings
• red, shiny, wet appearance

Correct answers: a, d, e

Rationale: The appearance of partial-thickness (deep) burns may include fluid-

filled vesicles (blisters) that are red, shiny, or wet (if vesicles have ruptured).Patients may have severe pain caused by exposure of nerve endings and may have mild to moderate edema.Pain management for the burn patient is most effective

when (SATA):

• a pain rating tool is used to monitor the patient's level

of pain

• painful dressing changes are delayed until the patient's

pain is completely relieved

• the patient is informed about and has some control

over the management of the pain

• a multi-modal approach is used (e.g., sustained-release

and short-acting opioids, NSAIDS, adjuvant analgesics).

• non-pharmacological therapies (e.g., music therapy,

distraction) replace opioids in the rehabilitation phase of a burn injury

Correct answers: a, c, d

Rationale: The use of a pain rating tool assists the nurse in the assessment,

monitoring, and evaluation of the pain management plan. The more control the patient has in managing the pain, the more successful the chosen strategies are. A selected variety of medications offer better pain relief for patients with burns, whose pain can be both continuous and treatment related over varying periods of time. It is not realistic to promise a patient that pain will be completely eliminated.It is not realistic to suggest that pain will be managed (during any phase of burn care) with nonpharmacologic pain management. Such management is meant to be adjuvant and individualized.

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

b.The clinical appearance of superficial partial-thickness burns includes erythema, blanching with pressure, and pain and minimal swelling with no vesicles or blistering during the first 24 hours.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

a, c, d, e An escharotomy (a scalpel incision through full-thickness eschar) is frequently required to restore circulation to compromised extremities. Daily cleansing and debridement as well as application of an antimicrobial ointment are expected interventions used to minimize infection and enhance wound healing. Pain control is essential in the care of a patient with a burn injury. With full-thickness burns, myoglobin and hemoglobin released into the bloodstream can occlude renal tubules. Adequate fluid replacement is used to prevent this occlusion.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

d.A hypermetabolic state occurs proportional to the size of the burn area. Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. Caloric needs are often in the 5000-kcal range. Failure to supply adequate calories and protein leads to malnutrition and delayed healing.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
• LR at 25 mL/h
• sodium bicarbonate 24 mEq q.4h

c.An infusion rate of 25 mL/hr is not sufficient to maintain adequate urine output in prevention and treatment of ATN.Electrical injury puts the patient at risk for myoglobinuria, which can lead to acute renal tubular necrosis (ATN). Treatment consists of infusing lactated Ringer's at 2-4 mL/kg/%TBSA, a rate sufficient to maintain urinary output at 75 to 100 mL/hr.Mannitol can also be used to maintain urine output. Sodium bicarbonate may be given to alkalinize the urine. The urine would also be monitored for the presence of myoglobin.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%
• 22.5%
• 27%
• 36%

b.Using the rule of nines, for these second- and third-degree burns, the face encompasses 4.5% of the body area, the entire right arm encompasses 9% of the body area, and the entire anterior trunk encompasses 18% of the body area. Since the patient has burns on only the right side of the anterior trunk, the nurse would assess that burn as encompassing half of the 18%, or 9%. Therefore adding the three areas together (4.5 + 9 + 9), the nurse would correctly calculate the extent of this patient's burns to cover approximately 22.5% of the total body surface area.

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
• access and manage pain and anxiety
• discuss possible reconstructive surgery

b Monitoring for complications (e.g., wound infection, pneumonia, contractures) is needed in the acute phase. Fluid replacement occurs in the emergent phase.Assessing and managing pain and anxiety occurs in the emergent and the acute phases. Discussing possible reconstructive surgeries is done in the rehabilitation phase.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

c.This patient is most likely experiencing hyperosmolar hyperglycemic syndrome (HHS). HHS dehydrates a patient rapidly. Thus HHS combined with the massive fluid losses of a burn tremendously increase this patient's risk for hypovolemic shock and serious hypotension. This is clearly the nurse's priority because the nurse must keep up with the patient's fluid requirements to prevent circulatory collapse caused by low intravascular volume. There is no mention of blood loss.Fluid resuscitation will help to correct the pH and serum potassium abnormalities.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

b.Albuterol (Ventolin) stimulates β-adrenergic receptors in the lungs to cause bronchodilation. However, it is a non-cardioselective agent so it also stimulates the β-receptors in the heart to increase the heart rate. Restlessness and GI upset may occur but will decrease with use. Hypokalemia does not occur with albuterol.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
• PO oxycodone and acetaminophen

b.IV medications are used for burn injuries in the emergent phase to rapidly deliver relief and prevent unpredictable absorption as would occur with the IM route. The PO route is not used because GI function is slowed or impaired due to shock or paralytic ileus, although oxycodone and acetaminophen may be used later in the patient's recovery. Tetanus toxoid may be administered but not for pain.