BURNS PRACTICE QUESTIONS

BURNS PRACTICE QUESTIONS

Leave the first rating Students also studied Terms in this set (14) Save Mark Klimek NCLEX Review Questio...25 terms allison_crasiPreview NP4 Teacher 54 terms quizlette170574848 Preview NP4 100 terms crisolmarquez Preview Chapte 10 terms jank 1) The nurse is providing care to a pediatric client who was admitted to the pediatric intensive care unit (PICU) with a partial-thickness thermal burn. When planning care for this client, which should the nurse consider regarding this type of burn?

• Partial-thickness burns are deeper than superficial

burns but still involve the epidermis only.

• A superficial partial-thickness burn extends from the

skin's surface into the papillary layer of the dermis.

• A deep partial-thickness burn is often bright red and

has a moist, glistening appearance with blister formation.

• A superficial partial-thickness burn is less painful than

a deep partial-thickness burn.

Answer: B

• A superficial partial-thickness burn extends from the skin's surface into the

papillary layer of the dermis. Partial-thickness burns are deeper than superficial burns, extending from the epidermis into the dermis layer as well. A superficial partial-thickness burn is often bright red and has a moist, glistening appearance with blister formation. A deep partial-thickness burn is less painful than a superficial partial-thickness burn because sensation is decreased at the site.2) A nurse working at a burn center is caring for a client with an electrical burn. According to the American Burn Association, how would this burn be classified?

• Minor
• Moderate
• Major
• Significant

Answer: C

• According to the American Burn Association, all electrical burns are classified

as major. Significant is not a classification according to the American Burn Association, and all other choices are incorrect.3) A client is evaluated after suffering severe burns to the torso and upper extremities. The nurse notes edema at the burned areas. Which of the following best describes the underlying cause of this manifestation?

• Decreased osmotic pressure in the burned tissue
• Reduced microvascular permeability at the site of the

burned area

• Increased potassium in the intracellular compartment
• Inability of the damaged capillaries to maintain fluids

in the cell walls

Answer: D

• Burn shock occurs during the first 24-36 hours after the injury. During this

period, there is a shifting of fluid volume that is the direct result of lost cell wall integrity at the injury site and in the capillary bed. There is an increase in microvascular permeability at the burn site. The osmotic pressure is also increased, causing fluid accumulation. Potassium ions leave the intracellular compartment, putting patients at risk for cardiac dysrhythmia due to hypokalemia.

4) Which data supports the nurse's concern that a client is at a high risk for a burn injury? Select all that apply.

• Part-time employment at a convenience store
• Diagnosis of hypertension
• Age 71 years
• Uses public transportation for grocery shopping
• Currently smokes one pack of cigarettes per day

Answer: C, E

5) An older adult client with severe burns over more than half of the body has an indwelling catheter. When evaluating the client's intake and output, which of the following should be taken into consideration?

• The amount of urine will be elevated due to the

amount of intravenous fluids administered during the initial phases of treatment.

• The amount of urine will be reduced in the first 24 to

48 hours and will then increase.

• The amount of urine will be reduced during the first 8

hours of the burn injury and will then increase as diuresis begins.

• The amount of urine output will be greatest in the first

24 hours after the burn injury.

Answer: B

• The client will have an initial reduction in urinary output. Fluid is reduced in the

initial phases as the body manages the insult caused by the injury and fluids are drawn into the interstitial spaces. After the shock period passes, the client will enter a period of diuresis. Diuresis begins between 24 and 36 hours after the burn injury.6) A client who sustained burns to both lower extremities reports feeling frustrated by not being able to provide self-care. Which nursing diagnosis would be appropriate for the client at this time?

• Ineffective Coping
• Powerlessness
• Anxiety
• Situational Low Self-Esteem

Answer: B

• The client is expressing frustration over not being able to provide self-care. The

nursing diagnosis most appropriate for the client at this time would be Powerlessness. There is not enough information to determine whether the client is or is not experiencing situational low self-esteem, ineffective coping, or anxiety.7) The nurse is planning care for a client in the acute stage of a burn injury. Which aspects of care should the nurse identify as a priority? Select all that apply.

• Nutrition
• Psychosocial support
• Pain management
• Fluid resuscitation
• Wound care

Answer: A, C, E

8) The nurse is evaluating the adequacy of the burn- injured client's nutritional intake. Which laboratory value is the best indicator of nutritional status?

• Creatine phosphokinase (CPK)
• Blood urea nitrogen (BUN) levels
• Hemoglobin
• Albumin level

Answer: D

• Albumin level is used to indicate protein synthesis and nutritional status.

Creatine phosphokinase is used to identify the presence of muscle injuries. BUN levels are used to evaluate kidney function. Hemoglobin levels will fluctuate with the stages of the burn injury, dependent on the fluid status.

9) The nurse is caring for a client who is to receive mechanical debridement of burn wounds. Which methods should the nurse anticipate using to complete this treatment? Select all that apply.

• Homograft
• Application of a topical agent to dissolve necrotic

tissue

• Irrigation of the burn wounds
• Application of wet-to-dry gauze dressings
• Hydrotherapy

Answer: C, D, E

10) How should the nurse position a client who is returned to the burn unit following a graft procedure to the leg?

• Place the client flat with the affected extremity

abducted.

• Elevate the head of bed 30 degrees
• Maintain the head of bed flat
• Elevate the affected extremity

Answer: D

• Elevating the affected extremity will reduce edema and promote perfusion.

Elevating the head of bed, leaving the head of bed flat, and abducting the extremity will not increase healing or improve the client's long-range prognosis.11) The nurse is planning to provide care to extended family members spanning three generations who are being treated for burn injuries after a fire. Based on an understanding of lifespan factors, the nurse should anticipate that which of the following is true?

• The 38-year-old pregnant mother is more likely to

require an allograft than the other members of the family.

• The 82-year-old grandmother is more likely to have

burns to a greater percentage of her total body surface area (TBSA) than younger family members.

• The 14-year-old son is less likely to experience edema

associated with his injuries than older members of the family.

• The 6-year-old daughter is more likely to go into burn

shock than the other members of the family.

Answer: B

• The older adult population is more likely to suffer burns to a greater

percentage of their TBSA than other age groups, largely because their skin is so much thinner and therefore more delicate than that of younger individuals. The other assumptions cannot be made based on patient age alone and depend on the depth and extent of the burns, which is information that is unavailable at this time.12) An adult burn patient is brought in to the intensive care unit (ICU) for treatment. Prior to sustaining the injury, the client was considered underweight for her height. The nurse understands that this may have important implications for the client because

• she will have lower fluid resuscitation calculations than

patients of normal weight.

• she will be at greater risk for developing cardiac or

renal insufficiencies.

• she will require more supportive care than patients

who are normal weight.

• she will lose as much as 20% of her preburn weight

during rehabilitation.

Answer: D

• During the acute and rehabilitative phases of the burn injury, the patient loses

as much as 20% of preburn weight. This has significant implications for all patients, especially those who are underweight at the time of injury. Fluid resuscitation calculations are based on the time of injury, not body weight. Patients with a past medical history of cardiac or renal problems are at an increased risk for cardiac and renal insufficiency regardless of weight. Children and older adults require more supportive care than other client populations because of differences in their skin and healing, not because of their body weight.

13) An adult burn patient is receiving fluid resuscitation of warm, lactated Ringer's solution during the first 24 hours following injury. The client's hourly urine output is being monitored to determine whether the resuscitation is adequate. The most recent reading is 1.10 mL/kg/hr. The nurse understands that this amount of urine output is

• slightly higher than the normal range.
• slightly lower than the normal range.
• within the normal range.
• extremely low.

Answer: A

• In adult patients with burn injuries who are receiving fluid resuscitation, urine

production of 0.5-1 mL/kg/hr is considered normal. Therefore, the nurse would understand that this patient's output is slightly high.14) A burn patient is currently in the acute stage. When did this stage begin, and when will it end?

• It began with the onset of the burn injury and will end

with fluid resuscitation.

• It began with wound closure and will end when the

patient's health is fully restored.

• It began with the start of diuresis and will end with the

closure of the burn wound.

• It began with the onset of the burn injury and will end

with the closure of the burn wound.

Answer: C.

• The acute stage begins with the start of diuresis and ends with the closure of

the burn wound, either by natural healing or by use of skin grafts. The emergent/resuscitative stage begins with the onset of the burn injury and ends with successful fluid resuscitation. The rehabilitative stage begins with wound closure and ends when the patient returns to the highest level of health restoration, which may take years.