Essential of Critical Care Nursing Chapter 17 Burns

Essential of Critical Care Nursing Chapter 17 Burns 4.8 (5 reviews) Students also studied Terms in this set (33) Science MedicineEmergency Medicine Save Nclex Questions for Shock - Critical ...32 terms karmageniePreview Renal Critical Care Exam 101 terms briannarowe7Preview Shock, Sepsis & Multiple Organ Dysf...187 terms anniedang_9Preview Critical 30 terms kati The nurse providing an overview of burns to a community group is teaching the causes for thermal burns. These

causes include:

Note: Credit will be given only if all correct choices and

no incorrect choices are selected.

Standard Text: Select all that apply.

• Contact with steam
• Exposure to hot liquids
• Being splashed with drain cleaner
• Stepping on hot charcoal
• Friction injuries

Correct Answer: 1,2,4,5

Rationale 1: Thermal burns include scald injuries from exposure to steam.

Rationale 2: Thermal burns include scald injuries from exposure to hot liquids.

Rationale 3: Drain cleaner represents a chemical source.

Rationale 4: Thermal burns include fire/flame injuries.

Rationale 5: Thermal burns include contact/friction injuries.

The nurse is explaining to the granddaughter of an 85- year-old patient that older persons are at greater risk for

scalding by hot water due to:

• This age group's adversity to taking showers
• An inclination to test the water's temperature
• Overall slower reaction time
• Loss of elasticity of skin tissue

Correct Answer: 3

Rationale 1: It is easier for older people to take a shower because they do not

have to risk slipping and falling while getting in and out of a bathtub.

Rationale 2: Older people can have a decrease in memory and forget to test the

water temperature.Rationale 3: Older and disabled individuals are at risk for scalding by hot bath water due to impaired sensation, slower reaction times, and decreased mobility.Rationale 4: Loss of skin elasticity is not a risk factor but could affect the severity.

A patient rescued from a small house fire is brought to the emergency department. There is no burn injury to the skin, however laboratory results show a CO level of 22%.Which intervention would the nurse expect to implement?

• Administer high-flow nebulizer treatment.
• Infuse a fluid bolus of lactated Ringer's solution.
• Begin a sodium bicarbonate drip.
• Give 100% oxygen by mask.

Correct Answer: 4

Rationale 1: This treatment will only open airways but not displace the carbon

monoxide.Rationale 2: This treatment would be used for fluid resuscitation, not gas exchange treatment.Rationale 3: A bicarbonate drip is only used for severe metabolic acidosis that is not responsive to other treatment.

Rationale 4: Carbon monoxide has a stronger affinity for hemoglobin than oxygen

does so it displaces oxygen as it binds with the hemoglobin. This impairs oxygen transport and tissue perfusion. The treatment is high-flow 100% oxygen.The critical care nurse is aware that the depth of burn injury is determined by the depth of tissue destruction and which other factors?

Note: Credit will be given only if all correct choices and

no incorrect choices are selected.

Standard Text: Select all that apply.

• Duration of the burn exposure
• Additional chronic medical conditions
• Skin thickness
• The cause of the burn
• Body part of the burn injury

The critical care nurse is aware that the depth of burn injury is determined by the depth of tissue destruction and which other factors?Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

• Duration of the burn exposure
• Additional chronic medical conditions
• Skin thickness
• The cause of the burn
• Body part of the burn injury

Which assessment finding by the nurse would be suggestive of a minor burn?

• The involved skin is deep reddish-brown in color and

edematous.

• Blisters begin to form on the skin within the first hour of

exposure.

• The skin remains intact because only the epidermal

layer is involved.

• Scarring will be evident on the edges of the burn in a

matter of hours.

Correct Answer: 3

Rationale 1: The color of a minor burn is not deep reddish-brown. The skin will be slightly edematous in a minor burn.

Rationale 2: Blisters will not form until after 24 hours, if at all.

Rationale 3: Superficial, or first-degree burns, involve only the epidermal layer of the skin, leaving the skin intact. The involved skin is pink to red in color and slightly edematous.

Rationale 4: These burns will heal without scarring in 3 to 6 days.

When assessing zone of coagulation of a third-degree

burn injury, the nurse would be alert for:

• The presence of pain
• Brisk capillary refill
• Surface of the wound that is dry and firm
• A bright red wound color

When assessing zone of coagulation of a third-degree burn injury, the nurse

would be alert for:

• The presence of pain
• Brisk capillary refill
• Surface of the wound that is dry and firm
• A bright red wound color

A patient comes to the emergency department with thermal burns to the left arm and shoulder. Which finding requires immediate attention by the nurse?

• Complaint of excessive thirst
• Loss of range of motion to the affected side
• Pain rating of 8 on a 1 to 10 scale
• Presence of coughing and hoarseness

Correct Answer: 4

Rationale 1: Complaint of thirst would be expected due to dehydration.

Rationale 2: Limited range of motion to the affected side is an expected finding.

Rationale 3: A high pain rating is an expected finding.

Rationale 4: Immediate signs of inhalation injury are changes to the mucosal lining of the oropharynx and larynx, including the presence of soot, hoarseness, edema, or blisters. The ABCs of resuscitation should be followed.

Which patient situation would present the greatest risk for

an inhalation injury? The patient:

• With a second-degree electrical burn of the hand
• Trapped on an elevator during a fire in a building
• With asthma who has extensive first-degree sunburn
• With a scalding injury from liquid splashed on the legs

Correct Answer: 2

Rationale 1: There is no smoke inhalation associated with an electrical burn.

Rationale 2: Being trapped on an elevator during a fire in a building poses the

greatest risk for an inhalation injury because of exposure to smoke or heat within an enclosed place.

Rationale 3: There is no smoke inhalation associated with sunburn.

Rationale 4: A scald injury is associated with hot water, not fire or smoke

inhalation.A patient in ICU with a burn circling the left upper leg suddenly experiences excruciating pain, pallor in the lower extremity, and loss of pedal pulse. The nurse would immediately notify the physician because this patient

might be developing:

• Compartment syndrome
• Inability to perform ADLs
• Nosocomial infection
• A deep vein thrombosis

Correct Answer: 1

Rationale 1: Circumferential extremity burns are at risk for developing

compartment syndrome in which the pressure within the muscle compartments is greater than that within the microvasculature. These symptoms are characteristic of a loss of circulation due to compression of the blood vessels.

Rationale 2: The ability to perform ADLs would likely not differ based on the

location of the burn.Rationale 3: All hospitalized patients experiencing burns are at risk for nosocomial infections.

Rationale 4: The symptoms of a deep vein thrombosis are more likely to be

swelling, warmth, and pain in the extremity.What would the nurse teach a patient with a burn injury about skin changes that occur following a large burn?

• Regulating body temperature returns with healing.
• Healed burn areas are more susceptible to mechanical

injury.

• Sensory perception never returns once healing of a

burn is complete.

• Vitamin D from sun exposure facilitates the healing

process.

Correct Answer: 2

Rationale 1: Patients with large burns are more susceptible to infection and have difficulty regulating body temperature even after the burn wound is healed.

Rationale 2: Healed burned areas are more susceptible to mechanical injury as a

consequence of changes in the texture of the skin and decrease of sensory perception.

Rationale 3: Sensation will eventually return but it may be altered.

Rationale 4: Sun exposure should be avoided because burned areas are more

susceptible to ultraviolet radiation.An alert patient at the scene of an explosion has a respiratory rate of 24 breaths per minute, a faint stridor, and soot on the face. The patient's heart rate is 120 beats per minute. Which action would be most appropriate to implement first?

• Administering humidified oxygen
• Placing on a cardiac monitor
• Inserting a large-bore angiocatheter
• Prophylactically intubating the patient

Correct Answer: 4

Rationale 1: Providing humidified oxygen would be appropriate after an airway is secured.Rationale 2: Placing on a cardiac monitor would be appropriate after an airway is secured.Rationale 3: Obtaining intravenous access would be appropriate after an airway is secured.Rationale 4: This is the most appropriate first action because the first assessment of a burn patient, whether at the scene or in the emergency department, would be a primary trauma survey beginning with the ABCs (airway, breathing, circulation). In order to secure an airway, this patient may be prophylactically intubated because there are signs of progressing respiratory stress and airway edema related to the tachypnea, stridor, and presence of soot, which places the patient at increased risk for inhalation injury. Procuring a secure endotracheal tube is very important because it is very difficult to reintubate a burn patient due to severe airway edema and neck swelling.

Following establishment of an airway, adequate breathing, and circulation, the nurse would focus next on which assessment following a burn injury?

• Determining total body surface area of the burn
• A quick check of neurologic status
• Psychologic trauma resulting from the incident
• Details of how the injury occurred

Correct Answer: 2

Rationale 1: The TBSA percentage and details of how the burn occurred would

also be important assessments but are done after the ABCs are completed.

Rationale 2: Once the initial ABCs have been assessed, neurologic status should

be examined. A burn patient should be awake and able to follow commands.Decreased neurologic status or unconsciousness may indicate anoxic injury or an additional neurologic injury.

Rationale 3: Physical needs and assessments must be completed prior to

psychologic needs.

Rationale 4: This would be done after the airway has been secured.

The burn unit nurse teaches a new staff nurse the priority nursing actions during the resuscitation phase of burn management. Which statement made by the inexperienced nurse indicates a need for further teaching?

• "We should promote an increased oral fluid intake."
• "A urinary catheter is usually inserted."
• "I'll get a nasogastric tube and suction equipment

ready."

• "All patients should have a large-bore IV access if

possible."

Correct Answer: 1

Rationale 1: "We should promote an increased oral fluid intake" is correct as a statement that requires further teaching. A nasogastric tube should be placed and suction applied to prevent aspiration; therefore, the patient will be NPO. This is also done to reduce the risk of the development of paralytic ileus.

Rationale 2: A urinary catheter should be placed prior to administering large

boluses of fluids.

Rationale 3: This statement reflects an appropriate action and preparation.

Rationale 4: Patients with major burns entering this phase should have large-bore intravenous access for fluid administration.A middle-aged male patient weighing 220 pounds incurred burns to 40% of the total body surface area.Using the Parkland formula, calculate his fluid resuscitation needs for the first 24 hours.

• 3,520 mL
• 35,200 mL
• 1,600 mL
• 16,000 mL

Correct Answer: 4

Rationale 1: Sixteen thousand milliliters is the correct amount of IV fluid for

resuscitation. The most commonly used formula is the Parkland formula, which recommends 4 mL/kg/% TBSA administered during the first 24 hours following a burn injury. Half of the total resuscitation volume is given in the first 8 hours. To solve the problem, first convert 220 pounds to kilograms: (220 ÷ 2.2 = 100 kg) 4 mL × 100 kg × 40% = 16,000 mL.The nurse plans care for a client with a major burn injury keeping in mind that the goals for initial burn wound

management would include:

Note: Credit will be given only if all correct choices and

no incorrect choices are selected.

Standard Text: Select all that apply.

• Decrease the risk of developing compartment

syndrome.

• Promote physical/psychological comfort.
• Prevent infection.
• Reduce the degree of scarring.
• Decrease fluid and electrolyte loss.

Correct Answer: 1,3,5

Rationale 1: The goals of wound management at this stage include decreasing the

risk of developing compartment syndrome.Rationale 2: Comfort is an important issue for treatment, however it is a secondary measure.

Rationale 3: The goals of wound management at this stage include preventing

infection.Rationale 4: Reduction of scarring is an issue that can be addressed at a later time.

Rationale 5: The goals of wound management at this stage are to decrease fluid

and electrolyte losses.