Tissue Integrity - Burns, NCLEX Burns Questions

Tissue Integrity - Burns, NCLEX Burns Questions Leave the first rating Students also studied Terms in this set (45) Science MedicineNursing Save

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28 terms Octobersky08 Preview Trauma 37 terms Rob A client presents to the ED with partial thickness burns to the Chest, Neck, and Shoulders. What is the priority nursing assessment?

• Vital signs
• Cardiovascular Assessment
• Respiratory Assessment
• Assessing airways and breathing
• Assessing airways and breathing

Upon assessing a stable burn patient, the nurse notes that the burn appears to only affect the epidermis and does not extend into the dermis. The nurse will document

this as:

• Scald
• Superficial Partial Thickness
• Partial Thickness
• Full Thickness
• Superficial Partial Thickness

Upon assessing a stable burn patient, the nurse notes that the burn appears to affect the epidermis has bubbled blisters and also extends into the dermis. The

nurse will document this as:

• Scald
• Superficial Partial Thickness
• Partial Thickness
• Full Thickness
• Partial Thickness

Upon assessing a stable burn patient, the nurse notes that the burn has exposed muscle and fat. The nurse will

document this as:

• Scald
• Superficial Partial Thickness
• Partial Thickness
• Full Thickness
• Full thickness

The nurse knows that she must be able to identify patients at high risk for complications secondary to a

burn. These would include: (select all that apply)

• Elderly
• Young children
• A patient with an eating disorder
• A patient with a chronic illness
• Middle-aged adults

A, B, C, D

A patient presents to the ED with burns circumventing both legs, the inguinal area, and the abdomen. Based on the Rule of 9s, the nurse documents a burn to what

percentage of the body:

• 54
• 72
• 55
• 73
• 55

A patient presented 2 days ago with severe burns and currently has a temperature of 38.2C and a BP of 130/88.

The nurses main concern is:

• The patient has a fever
• The patient is at risk for dehydration
• The patient may be developing an infection
• The patient has a perfusion problem
• The patient may be developing an infection

A patient in the acute phase of a wide-spread severe burn has decreased urine output, BP 110/70, Pulse 100 bpm, RR 30, SpO2 95% on 2L NC, and a temperature of 35.5C. What is the nurses priority concern?

• Airway patency
• RR
• BP
• Temp
• Temp - patients with burns are at risk for hypothermia that is life threatening

Parkland formula4mL LR x weight(kg) x % of body surface burned total volume to be given over 24 hours Parkland formula - how much is given in 1st 8 hours, 2nd 8 hours, and 3rd 8 hours 1st 8 - 1/2 total volume 2nd 8 - 1/4 total volume 3rd 8 - 1/4 total volume OR 1/2 total volume in first 8 hours, and 1/2 total volume over the remaining 16 hours

The nurse understands that in the emergent phase of

burn care, the priority interventions will involve: (select all

that apply)

• Establishing 2 22 Gauge IV lines
• Airway management
• Nutrition
• Prevent contractures
• Pain management

B, C, D, E

A is incorrect because the 2 IV lines should be 18 gauge or larger to facilitate such a large volum of fluids The nurse understands that in the rehabilitation phase of

burn care, the priority interventions will involve: (select all

that apply)

• Airway management
• Prevent contractures and skin breakdown
• Establish 2 IV lines
• Psychosocial assessments
• Facilitate wound healing

B, D, E

Airway management should already be under control in the rehabilitation phase Fluid resuscitation should be in the emergent phase A patient has experienced severe burns in both feet.Upon inspection of the feet, the nurse notes that they are blistered, red, painful and edematous. What is the priority intervention of the nurse?

• Stop fluid resuscitation
• Wrap feet in cool towels
• Monitor I&Os
• Notify HCP
• Monitor I&O

Client is most likely third spacing but is still dehydrated. The fluids should keep running, but output will ensure that the dehydration is resolving, and the third spacing should resolve with it.When looking at the labs of a burn victim in the acute phase, what would be an expected finding?

• Potassium 5.6 meq/L
• Sodium 155 meq/L
• Hematocrit 30%
• Hemogobin 11 g/dL

A - hyperkalemia is an expected finding in the acute phase of burns When looking at the labs of a burn victim in the emergent phase, what would be an expected finding?

• Potassium 3.2 meq/L
• Sodium 155 meq/L
• Hematocrit 48%

D) WBC 12,000

C

• 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. What 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

• Full-thickness skin destruction

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 of the following prescribed actions should be the nurse's priority?

• Monitoring urine output every 4 hours.
• Continuing to monitor the laboratory results.
• Increasing the rate of the ordered IV solution.
• Typing and crossmatching for a blood transfusion.

ANS: C

• Increasing the rate of the ordered IV solution.

The patient's laboratory results show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake 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. On admission to a burn unit, the urine output would be monitored more often than every 4 hours (likely every1 hour).

• A patient is admitted to the burn unit with burns to the

head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take?

• Encourage the patient to cough and auscultate the

lungs again.

• Notify the health care provider and prepare for

endotracheal intubation.

• Document the results and continue to monitor the

patient's respiratory rate.

• Reposition the patient in high-Fowler's position and

reassess breath sounds.

ANS: B

• Notify the health care provider and prepare for endotracheal intubation.

The patient's history and clinical manifestations suggest airway edema, and the health care provider should be notified immediately 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 administered 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 should the nurse infuse the IV fluids?

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

ANS: C

• 938 mL/hr

Half of the fluid replacement using the Parkland 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 will be most useful in determining whether the patient is receiving adequate fluid infusion?

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

ANS: D

• Measure hourly urine output.

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 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 adequate in determining that fluid infusions are maintaining adequate perfusion.