Med Surg - Burns NCLEX Review Questions

Med Surg - Burns NCLEX Review Questions 4.2 (6 reviews) Students also studied Terms in this set (16) Science MedicineNursing Save Med Surg Exam 3 Burns Questions 26 terms meg_jones2Preview Chapter 25 Burns NCLEX style quest...22 terms Amanda_Washington7 Preview NCLEX Style Practice Questions Bur...100 terms akrrissman84Preview Burns/ 20 terms kidn 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.

• One half of the total 24-hour fluid requirement should be administered in the

first 8 hours.Fluid resuscitation with the Parkland (Baxter) formula recommends that one half of the total fluid requirement should be administered in the first 8 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
• Reddening of the skin

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
• High-calorie and high-protein foods

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.A patient is admitted to the emergency department with first- and second-degree burns after being involved in a house fire. Which assessment findings would alert you to the presence of an inhalation injury? (select all that apply)?

• Singed nasal hair
• Generalized pallor
• Painful swallowing
• Burns on the upper extremities
• History of being involved in a large fire

A, B, C, E.

Reliable clues to the occurrence of inhalation injury is the presence of facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral and nasal membranes, carbonaceous sputum, history of being burned in an enclosed space, altered mental status, and "cherry red" skin color.When caring for a patient with an electrical burn injury, which order from the health care provider should the nurse question?

• Mannitol 75 gm IV
• Urine for myoglobulin
• Lactated Ringer's at 25 mL/hr
• Sodium bicarbonate 24 mEq every 4 hours
• Lactated Ringer's at 25 mL/hr

Electrical injury puts the patient at risk for myoglobinuria, which can lead to acute renal tubular necrosis (ATN). Treatment consists of infusing lactated Ringer's at 2-4 mL/kg/%TBSA, a rate sufficient to maintain urinary output at 75 to 100 mL/hr.Mannitol can also be used to maintain urine output. Sodium bicarbonate may be given to alkalinize the urine. The urine would also be monitored for the presence of myoglobin. An infusion rate of 25 mL/hr is not sufficient to maintain adequate urine output in prevention and treatment of ATN.A patient is admitted with second- and third-degree burns covering the face, entire right upper extremity, and the right anterior trunk area. Using the rule of nines, what should the nurse calculate the extent of these burns as being?

A. 18%

B. 22.5%

C. 27%

D. 36%

B. 22.5%

Using the rule of nines, for these second- and third-degree burns, the face encompasses 4.5% of the body area, the entire right arm encompasses 9% of the body area, and the entire anterior trunk encompasses 18% of the body area. Since the patient has burns on only the right side of the anterior trunk, the nurse would assess that burn as encompassing half of the 18%, or 9%. Therefore adding the three areas together (4.5 + 9 + 9), the nurse would correctly calculate the extent of this patient's burns to cover approximately 22.5% of the total body surface area.

An 82-year-old patient is moving into an independent living facility. What is the best advice the nurse can give to the family to help prevent this patient from being accidently burned in her new home?

• Cook for her.
• Stop her from smoking.
• Install tap water anti-scald devices.
• Be sure she uses an open space heater.
• Install tap water anti-scald devices.

Installing tap water anti-scald devices will help prevent accidental scald burns that more easily occur in older people as their skin becomes drier and the dermis thinner. Cooking for her may be needed at times of illness or in the future, but she is moving to an independent living facility, so at this time she should not need this assistance. Stopping her from smoking may be helpful to prevent burns but may not be possible without the requirement by the facility. Using an open space heater would increase her risk of being burned and would not be encouraged.The ambulance reports that they are transporting a patient to the ED who has experienced a full-thickness thermal burn from a grill. What manifestations should the nurse expect?

• Severe pain, blisters, and blanching with pressure
• Pain, minimal edema, and blanching with pressure
• Redness, evidence of inhalation injury, and charred

skin

• No pain, waxy white skin, and no blanching with

pressure

• No pain, waxy white skin, and no blanching with pressure

With full-thickness burns, the nerves and vasculature in the dermis are destroyed so there is no pain, the tissue is dry and waxy-looking or may be charred, and there is no blanching with pressure. Severe pain, blisters, and blanching occur with partial-thickness (deep, second-degree) burns. Pain, minimal edema, blanching, and redness occur with partial-thickness (superficial, first-degree) burns.In caring for a patient with burns to the back, the nurse knows that the patient is moving out of the emergent phase of burn injury when what happens?

• Serum sodium and potassium increase
• Serum sodium and potassium decrease.
• Edema and arterial blood gases improve.
• Diuresis occurs and hematocrit decreases.
• Diuresis occurs and hematocrit decreases.

In the emergent phase, the immediate, life-threatening problems from the burn, hypovolemic shock and edema, are treated and resolved. Toward the end of the emergent phase, fluid loss and edema formation end. Interstitial fluid returns to the vascular space and diuresis occurs. Urinary output is the most commonly used parameter to assess the adequacy of fluid resuscitation. The hemolysis of RBCs and thrombosis of burned capillaries also decreases circulating RBCs. When the fluid balance has been restored, dilution causes the hematocrit levels to drop.Initially sodium moves to the interstitial spaces and remains there until edema formation ceases, so sodium levels increase at the end of the emergent phase as the sodium moves back to the vasculature. Initially potassium level increases as it is released from injured cells and hemolyzed RBCs, so potassium levels decrease at the end of the emergent phase when fluid levels normalize.When teaching the patient about the use of range-of- motion (ROM), what explanations should the nurse give to the patient? Select all that apply.

• The exercises are the only way to prevent contractures.
• Active and passive ROM maintain function of body

parts.

• ROM will show the patient that movement is still

possible.

• Movement facilitates mobilization of leaked exudates

back into the vascular bed.

• Active and passive ROM can only be done while the

dressings are being changed.B, C.Active and passive ROM maintains function of body parts and reassures the patient that movement is still possible are the explanations that should be used.Contractures are prevented with ROM as well as splints. Movement facilitates mobilization of fluid in interstitial fluid back into the vascular bed. Although it is good to collaborate with physical therapy to perform ROM during dressing changes because the patient has already taken analgesics, ROM can and should be done throughout the day.

During the care of the patient with a burn in the acute phase, which new interventions should the nurse expect to do after the patient progressed from the emergent phase?

• Begin IV fluid replacement.
• Monitor for signs of complications.
• Assess and manage pain and anxiety.
• Discuss possible reconstructive surgery.
• Monitor for signs of complications.

Monitoring for complications (e.g., wound infection, pneumonia, contractures) is needed in the acute phase. Fluid replacement occurs in the emergent phase.Assessing and managing pain and anxiety occurs in the emergent and the acute phases. Discussing possible reconstructive surgeries is done in the rehabilitation phase.The patient in the acute phase of burn care has electrical burns on the left side of her body, type 2 diabetes mellitus, and a serum glucose level of 485 mg/dL. What should be the nurse's priority intervention to prevent a life-threatening complication of hyperglycemia for this burned patient?

• Replace the blood lost.
• Maintain a neutral pH.
• Maintain fluid balance.
• Replace serum potassium.
• Maintain fluid balance.

This patient is most likely experiencing hyperosmolar hyperglycemic syndrome (HHS). HHS dehydrates a patient rapidly. Thus HHS combined with the massive fluid losses of a burn tremendously increase this patient's risk for hypovolemic shock and serious hypotension. This is clearly the nurse's priority because the nurse must keep up with the patient's fluid requirements to prevent circulatory collapse caused by low intravascular volume. There is no mention of blood loss.Fluid resuscitation will help to correct the pH and serum potassium abnormalities.A patient with a burn inhalation injury is receiving albuterol (Ventolin) for bronchospasm. What is the most important adverse effect of this medication for the nurse to manage?

• GI distress
• Tachycardia
• Restlessness
• Hypokalemia
• Tachycardia

Albuterol (Ventolin) stimulates β-adrenergic receptors in the lungs to cause bronchodilation. However, it is a non-cardioselective agent so it also stimulates the β-receptors in the heart to increase the heart rate. Restlessness and GI upset may occur but will decrease with use. Hypokalemia does not occur with albuterol.The patient in the emergent phase of a burn injury is being treated for pain. What medication should the nurse anticipate using for this patient?

• SQ tetanus toxoid
• IV morphine sulfate
• IM hydromorphone (Dilaudid)
• PO oxycodone and acetaminophen (Percocet)
• IV morphine sulfate

IV medications are used for burn injuries in the emergent phase to rapidly deliver relief and prevent unpredictable absorption as would occur with the IM route. The PO route is not used because GI function is slowed or impaired due to shock or paralytic ileus, although oxycodone and acetaminophen may be used later in the patient's recovery. Tetanus toxoid may be administered but not for pain.The patient received a cultured epithelial autograft (CEA) to the entire left leg. What should the nurse include in the discharge teaching for this patient?

• Sit or lay in the position of comfort.
• Wear a pressure garment for 8 hours each day.
• Refer the patient to a counselor for psychosocial

support.

• Use the sun to increase the skin color on the healed

areas.

• Refer the patient to a counselor for psychosocial support.

In the rehabilitation phase, the patient will work toward resuming a functional role in society, but frequently there are body image concerns and grieving for the loss of the way they looked and functioned before the burn, so continued counseling helps the patient in this phase as well. Putting the leg in the position of comfort is more likely to lead to contractures than to help the patient. If a pressure garment is prescribed, it is used for 24 hours per day for as long as 12 to 18 months.Sunlight should be avoided to prevent injury, and sunscreen should always be worn when the patient is outside.