NURS 342 Test #4 - Ch. 24 - Burns - Lewis 10th ed. practice NCLEX

NURS 342 Test #4 - Ch. 24 - Burns - Lewis 10th ed. practice NCLEX Leave the first rating Students also studied Terms in this set (10) Science MedicineNursing Save Chapter 24 Burns Lewis 39 terms mattiethrift Preview

Nursing Care: Head Injury

16 terms breanna_hinkle Preview Pacemakers and ICDs (Nursing 4 TE...Teacher 32 terms laura_mobleyPreview NCLEX 100 term akr Knowing the most common causes of household fires, which prevention strategy would the nurse focus on when teaching about fire safety?

• Set hot water temp at 140°F
• Use only hardwired smoke detectors.
• Encourage regular home fire exit drills.
• Never permit older adults to cook unattended.
• Encourage regular home fire exit drills.

Rationale: A risk-reduction strategy for household fires is to encourage regular home fire exit drills. Hot water heaters set at 140° F (60° C) or higher are a burn hazard in the home; the temperature should be set at less than 120° F (40° C).Installation of smoke and carbon monoxide detectors can prevent inhalation injuries. Hard-wired smoke detectors do not require battery replacement; battery- operated smoke detectors may be used. Supervision of older adults who are cooking is necessary if cognitive impairment is present.The injury that is least likely to result in a full thickness burn is

• sunburn.
• scald injury.
• chemical burn.
• electrical injury.
• sunburn.

Rationale: Full-thickness burns may be caused by contact with flames, scalding

liquids, chemicals, tar, or electrical current.When assessing a patient with a partial-thickness burn, the nurse would expect to find (select all that apply)

• blisters.
• exposed fascia.
• exposed muscles.
• intact nerve endings.
• red, shiny, wet appearance.
• blisters..
• intact nerve endings.
• red, shiny, wet appearance.

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.

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 the vascular space.
• sequestering of sodium and water in interstitial fluid.
• hemolysis of red blood cells from large volumes of

rapidly administered fluid.

• sequestering of sodium and water in interstitial fluid.

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, high-carbohydrate diet.
• increase normal caloric intake by about 3 times
• eat at least 1500 calories/day in small, frequent meals.
• eat a gluten-free diet for the chemical effect on

nitrogen balance

• eat a high-protein, high-carbohydrate diet.

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 burn 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.

• observe the wound for signs of infection during dressing changes.

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 (select all that apply)

• 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 multimodal approach is used (e.g., sustained-release

and short-acting opioids, NSAIDs, adjuvant analgesics).

• nonpharmacologic therapies (e.g., music therapy,

distraction) replace opioids in the rehabilitation phase of a burn injury.

• a pain rating tool is used to monitor the patient's level of pain.
• the patient is informed about and has some control over the management of

the pain.

• a multimodal approach is used (e.g., sustained-release and short-acting opioids,

NSAIDs, adjuvant analgesics).

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 the rehabilitation phase of burn recover is

• applying pressure garments.
• repositioning the patient every two hours.
• performing active ROM at lease every 4 hours.
• massaging the new tissue with water-based

moisturizers.

• applying pressure garments.

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 admitted to the burn center with burns to his head, neck, and anterior and posterior chest 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?

• Encourage the patient to cough and auscultate the

lungs again.

• Obtain vital signs, oxygen saturation, and a STAT

arterial blood gas.

• Document the findings and continue to monitor the

patient's breathing.

• Anticipate the need for endotracheal intubation and

notify the physician.

• Anticipate the need for endotracheal intubation and notify the physician.

Rationale: Inhalation injury results in exposure of the respiratory tract to intense heat or flames with inhalation of noxious chemicals, smoke, or carbon monoxide (CO). The nurse should anticipate the need for intubation and mechanical ventilation because this patient is demonstrating signs of severe respiratory distress.A patient is recovering from second- and third-degree burns over 30% of his body and the burn care team is planning 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 the caregiver proper wound care

to be performed at home.

• review the patient's current health care status and

readiness for discharge home.

• give the patient written information and websites for

information for burn survivors.

• review the patient's current health care status and readiness for discharge

home.

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 burn 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.