Chapter 25 Burns NCLEX style questions with rationales

Chapter 25 Burns NCLEX style questions with rationales ScienceMedicineNursing Amanda_Washington7 Save NCLEX Style Practice Questions Bur...100 terms akrrissman84Preview Burns/NCLEX QUESTIONS 20 terms kidniki77Preview Nclex Questions for Shock - Critical ...32 terms karmageniePreview NCLEX 25 terms Lau 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.A patient is admitted to the burn center with burns of his head and neck, chest, and back after an explosion in his garage. On assessment, the nurse auscultates wheezes throughout the lung fields. On reassessment, the wheezes are gone and the breath sounds are greatly diminished.Which action is the most appropriate for the nurse to take next?

• obtain vital signs and a STAT ABG
• encourage the patient to cough and auscultate the lungs again
• document the findings and continue to monitor the patient's breathing
• anticipate the need for endotracheal intubation and notify the physician

Correct answer: d

Rationale: Inhalation injury results in exposure of the respiratory tract to intense heat or flames with inhalation of noxious chemicals, smoke, or carbon monoxide. The nurse should anticipate the need for intubation and mechanical ventilation because this patient is demonstrating signs of severe respiratory distress.

Fluid and electrolyte shifts that occur during the early emergent phase of a burn injury include:

• adherence of albumin to vascular walls
• movement of potassium into vascular space
• sequestering of sodium and water in interstitial fluid
• hemolysis of red blood cells from large volumes of rapidly administered fluid

Correct answer: c

Rationale: During the emergency phase, sodium rapidly shifts to the interstitial spaces and remains there until edema formation ceases.

To maintain a positive nitrogen balance in a major burn, the patient must:

• eat a high-protein, low-fat, high-carbohydrate diet
• increase normal caloric intake by about three times
• eat at least 1500 calories/day in small, frequent meals
• eat rice and whole wheat for the chemical effect on nitrogen balance.

Correct answer: a

Rationale: The patient should be encouraged to eat high-protein, high-carbohydrate foods to meet increased caloric needs. Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. Failure to supply adequate calories and protein leads to malnutrition and delays in healing.A patient has 25% TBSA burned from a car fire. His wounds have been debrided and covered with a silver-impregnated dressing. The nurse's

priority intervention for wound care would be to:

• reapply a new dressing without disturbing the wound bed
• observe the wound for signs of infection during dressing changes
• apply cool compresses for pain relief in between dressing changes
• wash the wound aggressively with soap and water three times a day.

Correct answer: b

Rationale: Infection is the most serious threat with regard to further tissue injury and possible sepsis.

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.

A therapeutic measure used to prevent hypertrophic scarring during rehabilitation phase of burn recover is:

• applying pressure garments
• repositioning the patient every 2 hours
• performing active ROM at least every 4 hours
• massaging the new tissue with water-based moisturizers

Correct answer: a

Rationale: Pressure can help keep a scar flat and reduce hypertrophic scarring. Gentle pressure can be maintained on the healed burn with custom-fitted pressure garments.A patient is recovering from second- and third-degree burns over 30% of his body and is now ready for discharge. The first action the nurse

should take when meeting with the patient would be to:

• arrange a return-to-clinic appointment and prescription for pain medications
• teach the patient and caregiver proper wound care to be performed at home
• review the patient's current health care status and readiness for discharge to home
• give the patient written discharge information and websites for additional information for burn survivors.

Correct answer: c

Rationale: Recovery from a burn injury to 30% of total body surface area (TBSA) takes time and is exhausting, both physically and emotionally, for the patient. The health care team may think that a patient is ready for discharge, but the patient may not have any idea that discharge is being contemplated in the near future. Patients are often very fearful about how they will manage at home. The patient would benefit from the nurse's careful review of his or her progress and readiness for discharge; then the nurse should outline the plans for support and follow-up after discharge.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.

b.Fluid resuscitation with the Parkland (Baxter) formula recommends that one half of the total fluid requirement should be administered in the first

• hours, one quarter of total fluid requirement should be administered in the second 8 hours, and one quarter of total fluid requirement should

be administered in the third 8 hours.

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.