Chapter 55. Nursing Care of Patients With Burns

Chapter 55. Nursing Care of Patients With Burns

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Students also studied Terms in this set (22) Science MedicineNursing Save Chapter 55. Nursing Care of Patients...15 terms rlgadsPreview Chapter 54. Nursing Care of Patient...30 terms TaylbbbbPreview Chapter 54. Nursing Care of Patient...30 terms teffakmposPreview Chapte 22 terms alw . The nurse is at the scene of a fire caring for a patient with a thermal burn on the face, chest, and abdomen.What action should the nurse perform first?

• Ensure an open airway.
• Cover the burns with sterile dressings.
• Wash the burn gently with dilute antiseptic.
• Pour cool, clean water over the burned areas.
• Ensure an open airway.

. The nurse is caring for a patient with burns covering the entire surface of both arms and the anterior trunk.Approximately what percentage of the patients body surface area has been affected?

• 36%

The nurse is caring for a patient in the initial phase of treatment for a partial-thickness burn. The patient has been stabilized, with blood pressure 140/88 mm Hg, pulse 78 beats/min, respirations 22 breaths/min, and temperature 97.4F (36.3C). Which new assessment finding should be immediately communicated to the health care provider (HCP)?

• Report of increasing pain
• Temperature 99F (37.2C)
• Serum-filled blister formation
• Blood pressure 122/74 mm Hg
• Blood pressure 122/74 mm Hg

The nurse is caring for a patient who is 2 days post- inhalation burn injury from a house fire. Which outcome best indicates that nursing interventions for impaired gas exchange have been effective?

• PaCO2 is 56 mm Hg.
• The patient is afebrile.
• The patient is alert and oriented.
• Peripheral pulses are present and strong
• The patient is alert and oriented.

A patient is having a surgical procedure done to promote peripheral tissue perfusion in an extremity with full- thickness circumferential burns. What term should the nurse use to document this procedure?

• Excision
• Skin graft
• Dbridement
• Escharotomy
• Escharotomy

The nurse is caring for a patient who is receiving fluid replacement after being burned on 37% of the body.Nursing assessment reveals a blood pressure of 80/60 mm Hg, heart rate of 120 beats/min, and urine output of 10 mL over the past hour. After reporting these findings, which order should the nurse expect to be prescribed for this patient?

• Discontinue the IV fluid infusion.
• Change the IV fluid to dextrose and water.
• Increase the amount of IV fluid administered per hour.
• Decrease the amount of IV fluid administered per hour.
• Increase the amount of IV fluid administered per hour.

The nurse is providing wound care to a patients skin graft donor sites used for burn treatment. For which type of wound is this nurse providing care?

• Skin tear
• Full thickness
• Split thickness
• Partial thickness
• Partial thickness

A donor site is considered a partial-thickness wound. A. A skin tear is accidental. B.

• Full and split thicknesses describe different types of grafts, not donor sites.

The nurse is caring for a patient admitted to the burn unit with burns to 45% of the body. After 3 days, the nurse notes that the patients temperature is newly elevated at 100.2F (37.9C), and the patient exhibits newonset agitation and confusion. What should the nurse do first?

• Increase oral fluids to 3000 mL/day.
• Notify the registered nurse (RN) or primary care

provider.

• Monitor the patient for further changes in mental

status.

• Administer a prn dose of acetaminophen (Tylenol) for

the fever.

• Notify the registered nurse (RN) or primary care provider.

A patient is admitted to the emergency department with chemical burns to the chest and abdomen. The RN immediately begins a sterile saline lavage. What should the licensed practical nurse (LPN) do to assist during this procedure?

• Apply a neutralizing agent.
• Apply ice to the burned area.
• Remove the patients clothing.
• Prepare intravenous morphine for administration by the

RN

• Remove the patients clothing.

The nurse is caring for a patient 3 days following a split- thickness burn injury from a fire. Which observation indicates that nursing interventions to promote cardiac output have been effective?

• Blood pressure is 128/66 mmHg.
• Radial pulses are thready at 112/min.
• Urine output is 1050 mL in 24 hours.
• Patient weight is 4 pounds less than admission weight.
• Blood pressure is 128/66 mmHg.

A patient is diagnosed with superficial partial-thickness burns. How many days should the nurse instruct the patient that these burns will need to heal?

• 1 to 5
• 7 to 10
• 14 to 21
• 28 to 45
• 7 to 10

A patient has burns on both legs and in the genital/perineum area. What is this patients percentage of burned area?

• 18%
• 19%
• 37%
• 54%
• 37%

A patient wants to know how long it will take to know if a skin graft used to cover a burn site is successful. How many days should the nurse explain as needed for graft vascularization to occur?

• 1 to 2
• 3 to 5
• 7 to 9
• 11 to 13
• 3 to 5

Graft take, or vascularization, is complete in about 3 to 5 days. A. It takes longer than 1 to 2 days for vascularization to occur. C. D. Vascularization should occur before 7 days and does not take up to 13 days . The nurse notes that a patient with full thickness burns has an increase in hematocrit level. What should the nurse realize is causing this change in laboratory value?

• Loss of intravascular fluid
• Destruction of blood vessels
• Increased function of platelets
• Migration of white blood cells
• Loss of intravascular fluid

A patient with a deep partial thickness burn is prescribed wet to dry gauze dressings. Which type of debridement is the nurse performing with this dressing?

• Surgical
• Chemical
• Mechanical
• Escharotomy
• Mechanical

Mechanical debridement can involve the use of scissors and forceps to manually excise loose nonviable tissue, or the use of wet-to-moist or wet-to-dry fine-mesh gauze dressings. A. Surgical debridement is the excision of full-thickness and deep partial-thickness burns. B. Chemical debridement involves the use of a proteolytic enzymatic debriding agent that digests necrotic tissue. D. An escharotomy is a linear excision through the eschar to the superficial fat that allows for expansion of the skin and return of blood flow or chest expansion The nurse is caring for a patient who sustained a partial- thickness burn to the face. Which assessment findings should the nurse expect? (Select all that apply.)

• Blisters
• Charred skin
• White patches
• Bright red color
• Leathery character
• Blanching when touched
• Blisters
• Bright red color
• Blanching when touched

The nurse is assisting with the care of a patient admitted to the emergency department with chemical burns across the chest and hands. Which actions should be included in the plan of care? (Select all that apply.)

• Apply ice packs to burn sites.
• Remove all contaminated clothing.
• Cover the patient with a clean sheet.
• Apply neutralizing agent to burn area.
• Obtain a history of the event and burning agent.
• Provide copious tepid water lavage for 20 minutes
• Remove all contaminated clothing
• Cover the patient with a clean sheet.
• Obtain a history of the event and burning agent.
• Provide copious tepid water lavage for 20 minutes

Initiate immediate copious tepid water lavage for 20 minutes for all chemical burns, along with simultaneous removal of contaminated clothing. Cover the patient with a clean sheet and obtain a history of the burning agent. D. Do not neutralize chemical because this takes too much time, and the resulting reaction may generate heat and cause further skin injury. A. Do not apply ice.The nurse is caring for a patient with extensive burns. For which systemic responses to the burn should the nurse monitor the patient? (Select all that apply.)

• Hypovolemia
• Peptic ulceration
• Decreased metabolism
• Increased platelet function
• Increased oxygen consumption
• Depression of immunoglobulins
• Hypovolemia
• Peptic ulceration
• Increased oxygen consumption
• Depression of immunoglobulins

Following a major burn, increased capillary permeability leads to the leakage of plasma and proteins into the tissue, resulting in the formation of edema and loss of intravascular volume. C. Metabolic demands are very Test Bank - Understanding Medical-Surgical Nursing 6e (Williams and Hopper) 888 high in patients with burns, which in turn increases oxygen consumption. D.Intense heat decreases platelet function and half-life. With the skin destroyed, the body loses its first line of defense against infection. Major burns also cause a depression of the immunoglobulins IgA, IgG, and IgM. Peptic ulcers can occur due to decreased gastric motility and the stress response.