Chapter 26: Burns - Exam 2

Chapter 26: Burns - Exam 2

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43 terms SMloveforyou Preview Lewis M 45 terms use When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes dry, pale, and hard skin. the patient states that the burn is not painful. Which term would the nurse use to document the burn depth?

• First-degree skin destruction
• Full-thickness skin destruction
• Deep partial-thickness skin destruction
• Superficial partial-thickness skin destruction

ANS: B

With full-thickness skin destruction, the appearance is pale and dry or leathery, and the area is painless because of the associated nerve destruction. Erythema, swelling, and blisters point to a deep partial-thickness burn. With superficial partial-thickness burns, the area is red, but no blisters are present. First-degree burns exhibit erythema, blanching, and pain.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 58%, Hgb

18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which prescribed action would be the nurse's priority?

• Monitoring urine output
• Scheduling additional laboratory tests
• Increasing the rate of the ordered IV solution
• Typing and crossmatching for a blood transfusion

ANS: C

The patient's laboratory results show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased.Additional lab tests can be scheduled after the fluid volume is increased. Because the hematocrit and hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase once the patient's fluid balance has been restored. Urine output would be monitored frequently, likely every hour, and adequate fluid volume will be needed to maintain the urine output.

A patient is admitted with burns to the head, face, and hands. Initially, wheezes are heard throughout the chest, but an hour later, the lung sounds are decreased, and no wheezes are audible. Which action would the nurse take?

• Encourage the patient to cough and auscultate the

lungs again.

• Notify the health care provider and prepare for

endotracheal intubation.

• Document theassessment and continue to monitor

thepatient's respiratory rate.

• Reposition thepatient in high-Fowler's position and

reassess breath sounds.

ANS: B

The patient's history and clinical manifestations suggest airway edema, and the health care provider should be notified at once so that intubation can be done rapidly. 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.A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. the initial volume of fluid to be given in the first 24 hours is 30,000 mL. the initial rate of administration is 1875 mL/hr.After the first 8 hours, what rate would the nurse infuse the IV fluids?

• 219 mL/hr
• 625 mL/hr
• 938 mL/hr
• 1875 mL/hr

ANS: C

Half of the fluid replacement using theParkland formula is administered in the first

• hours and the other half over the next 16 hours. In this case, the patient should

receive half of the initial rate, or 938 mL/hr.During the emergent phase of burn care, which assessment is most useful in determining whether the patient is receiving adequate fluids?

• Check skin turgor.
• Monitor daily weight.
• Assess mucous membranes.
• Measure hourly urine output.

ANS: D

When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hr.the patient's weight is not as useful in this situation because of the effects of third spacing and evaporative fluid loss. Mucous membrane assessment and skin turgor also may be used, but they are not as useful in determining that fluid infusions are maintaining adequate perfusion.A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. Which action would the nurse plan to take to maintain adequate patient nutrition?

• Administer vitamins and minerals intravenously.
• Insert a feeding tube and initiate enteral nutrition.
• Infuse total parenteral nutrition via a central catheter.
• Encourage an oral intake of at least 5000 kcal per day.

ANS: B

Enteral nutrition can usually be started 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.Vitamins and minerals may be given 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 unless the gastrointestinal tract is not available for use.Which nursing action prevents cross contamination when the patient's full-thickness burn wounds are exposed?

• Using sterile gloves when removing dressings
• Keeping the room temperature at 70F (20C)
• Wearing gown, cap, mask, and gloves during care
• Giving IV antibiotics to prevent bacterial colonization

ANS: C

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.When removing contaminated dressings and washing the dirty wound, use non- sterile, disposable gloves. the room temperature would be kept at 85F for patients with open burn wounds to prevent shivering. Systemic antibiotics are not well absorbed into deep burns because of the lack of circulation.

A nurse is caring for a patient who has burns of the ears, head, neck, and right arm and hand. In which position would the nurse place the patient?

• Place the right arm and hand flexed in a position of

comfort.

• Elevate the right arm and hand on pillows and extend

the fingers.

• Assist the patient to a supine position with a small

pillow under the head.

• Position the patient in a side-lying position with rolled

towel under the neck.

ANS: B

The right hand and arm should be elevated to reduce swelling and the fingers extended to avoid flexion contractures (even though this position may not be comfortable for the patient). the patient with burns of the ears should not use a pillow for the head because this will put pressure on the ears, and the pillow may stick to the ears. Patients with neck burns should not use a pillow or rolled towel because the head should be kept in an extended position to avoid contractures.A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and reports numbness in the toes. Which action would the nurse take first?

• Monitor the pulses every hour.
• Notify the health care provider.
• Elevate both legs above heart level with pillows.
• Encourage the patient to flex and extend the toes.

ANS: B

The decrease in pulse and numbness in a patient with circumferential burns shows decreased circulation to the legs and the likely need for an escharotomy.Monitoring the pulses is not an adequate response to the decrease in circulation.Elevating the legs or increasing toe movement will not improve the patient's circulation.Esomeprazole is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which nursing assessment would best evaluate the effectiveness of the drug?

• Bowel sounds
• Stool frequency
• Stool occult blood
• Abdominal distention

ANS: C

H2 blockers and proton pump inhibitors are given to prevent Curling's ulcer and gastrointestinal bleeding in the patient who has sustained burn injuries. Proton pump inhibitors usually do not affect bowel sounds, stool frequency, or appetite.Which prescribed drug would the nurse plan to administer before scheduled wound debridement on a patient with partial-thickness burns?

• ketorolac
• lorazepam (Ativan)
• gabapentin (Neurontin)
• hydromorphone (Dilaudid)

ANS: D

Opioid pain medications are the best choice for pain control during a painful procedure. the other drugs are used as adjuvants to enhance the effects of opioids.A young female patient with deep partial-thickness face and neck burns is in the rehabilitation phase. Which statement by the patient indicates that a problem with body image is resolving?

• "I'm glad to know the scars will be gone soon."
• "I don't use a pillow, so my neck will be OK."
• "I think dark beige makeup will cover this scar."
• "I don't think my boyfriend will want to look at me now."

ANS: C

The willingness to use strategies to enhance appearance is an indication that the disturbed body image is resolving. Expressing concern about the appearance to others shows a willingness to discuss appearance but not resolution of the problem. Because deep partial-thickness burns leave permanent scars, a statement that the scars are temporary shows denial rather than resolution of the problem. Avoiding using a pillow will help prevent contractures, but it does not address the problem of disturbed body image.

A patient admitted with burns over 30% of the body surface 3 days ago has dramatically increased urine output today. How would the nurse interpret this finding?

• Diuresis indicates development of acute kidney injury.
• Diuresis reflects normalizing capillary permeability.
• Increased urine volume signals a likely urinary

infection.

• Increased urine volume requires increased calorie

intake.

ANS: B

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. This usually happens about 72 hours after the initial injury. A low urine output in the early days after a burn injury would raise concern for possible kidney injury form hypovolemia. Patients with burns are susceptible to infection and may need additional calories for wound healing, however, increased urine volume is not associated with a urinary tract infection or a need for additional calories.A patient with burns covering 40% total body surface area (TBSA) is in the acute phase of burn treatment.Which snack would the nurse recommend as providing the most support for wound healing?

• Banana
• Orange gelatin
• Vanilla milkshake
• Whole grain bagel

ANS: C

A patient with a burn injury needs high-protein and high-calorie food intake, and the milkshake is the highest in these nutrients. the other choices are not as nutrient dense as the milkshake. Gelatin is high in sugar. the bagel is a good carbohydrate choice but low in protein. Bananas are a good source of potassium but are not high in protein and calories.A patient has just arrived in the emergency department after an electrical burn from exposure to a high-voltage current. Which assessment is the priority?

• Oral temperature
• Peripheral pulses
• Extremity movement
• Pupil reaction to light

ANS: C

All patients with electrical burns would be considered at risk for cervical spine injury, and assessment of extremity movement will provide baseline data. the other assessment data are necessary but not as essential as determining the cervical spine status.A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital. Which action would the nurse take first?

• Stay at the bedside and reassure the patient.
• Administer the ordered morphine sulfate IV.
• Assess orientation and level of consciousness.
• Use pulse oximetry to check oxygen saturation.

ANS: D

Agitation in a patient who may have suffered inhalation injury might indicate hypoxia, and this should be assessed by the nurse first. Administration of morphine may be indicated if the nurse determines that the agitation is caused by pain. Assessing level of consciousness and orientation is appropriate but not as essential as determining whether the patient is hypoxemic. Reassurance is not helpful to reduce agitation in a hypoxemic patient.A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action would the nurse take first?

• Auscultate for breath sounds.
• Determine the extent and depth of the burns.
• Give the prescribed hydromorphone (Dilaudid).
• Infuse the prescribed lactated Ringer's solution.

ANS: A

A patient with facial and chest burns is at risk for inhalation injury and assessment of airway and breathing is the priority. the other actions will be completed after airway management is assured.