burns nclex – Flashcards
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When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the skin is red, swollen, and covered with large blisters. The patient states that they are very painful. The nurse will document the injury as ______________
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deep partial-thickness skin destruction. rationale: The erythema, swelling, and blisters point to a deep partial-thickness burn. With full-thickness skin destruction, the appearance is pale and dry or leathery and the area is painless because of the associated nerve destruction. With superficial partial-thickness burns, the area is red, but no blisters are present.
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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 56%, Hb 17.2 mg/dL (172 g/L), serum K+ 4.8 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse anticipate taking?
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Increase the rate of the ordered IV solution. rationale: The patient's lab data show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Documentation and continuing to monitor are inadequate responses to the data. Since the hematocrit and hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase.
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A patient is admitted to the burn unit with burns to the upper body and head after a garage fire. 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?
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Notify the health care provider and prepare for endotracheal intubation. rationale: The patient's history and clinical manifestations suggest airway edema and the health care provider should immediately be notified so that intubation can rapidly be done. 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.
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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, the nurse will decrease the fluid infusion rate to ______________
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938 mL/hour. rationale: Half of the fluid replacement using the Parkland formula is administered in the first 8 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.
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During the emergent phase of burn care, which nursing action will be most useful in determining whether the patient is receiving adequate fluid infusion?
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Measure hourly urine output. rationale: When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hour. 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.
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To maintain adequate nutrition for a patient who has just been admitted with a 40% total body surface area (TBSA) burn injury, the nurse will plan to ____________
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insert a feeding tube and initiate enteral feedings. rationale: Enteral feedings can usually be initiated during the emergent phase at low rates and increased over 24 to 48 hours to the goal rate. During the emergent phase, the patient will be unable to eat enough calories to meet nutritional needs and may have a paralytic ileus that prevents adequate nutrient absorption. Vitamins and minerals may be administered during the emergent phase, but these will not assist in meeting the patient's caloric needs. Parenteral nutrition increases the infection risk, does not help preserve gastrointestinal function, and is not routinely used in burn patients.
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A patient with deep partial-thickness and full-thickness burns of the face and chest is having the wounds treated with the open method. Which nursing action will be included in the plan of care?
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Wear gowns, caps, masks, and gloves during all care of the patient. rationale: Use of gowns, caps, masks, and gloves during all patient care will decrease the possibility of wound contamination for a patient whose burns are not covered. Restricting all visitors is not necessary and will have adverse psychosocial consequences for the patient. The room temperature should be kept at approximately 85° F for patients with open burn wounds. Systemic antibiotics are not well absorbed into deep burns because of the lack of circulation.
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Which action will be included in the plan of care for a patient who has burns of the ears, head, neck, and right arm and hand?
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Elevate the right arm and hand on pillows and extend the fingers. rationale: The right hand and arm should be elevated to reduce swelling and the fingers extended to avoid flexion contractures (even though this position may not be comfortable for the patient). The patient with burns of the ears should not use a pillow since this will put pressure on the ears and may stick to the ears. Patients with neck burns should not use a pillow, since the head should be maintained in an extended position in order to avoid contractures.
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A patient with circumferential burns of both arms develops a decrease in radial pulse strength and numbness in the fingers. Which action should the nurse take?
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Notify the health care provider. rationale: The decrease in pulse in a patient with circumferential burns indicates decreased circulation to the arms and the need for escharotomy. Monitoring the pulses is not an adequate response to the decrease in circulation. Elevating the hands or increasing hand movement will not improve the patient's circulation.
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Ranitidine (Zantac) is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which information will the nurse collect to evaluate the effectiveness of the medication?
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Stools for occult blood rationale: H2 blockers are given to prevent Curling's ulcer in the patient who has suffered burn injuries. H2 blockers do not impact on bowel sounds, stool frequency, or appetite.
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Which of these medications that are prescribed as needed for a patient who has partial thickness burns will be best for the nurse to use before wound debridement?
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hydromorphone (Dilaudid) rationale: Opioid pain medications are the best choice for pain control. The other medications are used as adjuvants to enhance the effect of opioids.
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A 21-year-old patient who is in the rehabilitation phase after having deep partial-thickness face and neck burns has a nursing diagnosis of disturbed body image. Which action by the patient indicates that the problem is resolving?
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Asking about how to use make-up to cover up the scars. rationale: The willingness to use strategies to enhance appearance is an indication that the disturbed body image is resolving. Expressing feelings about the scars indicates a willingness to discuss appearance, but not resolution of the problem. Because deep partial-thickness burns leave permanent scars, a statement that the scars are temporary indicates denial rather than resolution of the problem. Avoiding using a pillow will help prevent contractures, but it does not address the problem of disturbed body image.
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The nurse caring for a patient admitted with burns over 30% of the body surface will recognize that the patient has moved from the emergent to the acute phase of the burn injury when ______________
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the patient has large quantities of pale urine. rationale: At the end of the emergent phase, capillary permeability normalizes and the patient begins to diurese large amounts of urine with a low specific gravity. Although this may occur at about 48 hours, it may be longer in some patients. Blisters and edema begin to resolve, but this process requires more time. White blood cells may increase or decrease, based on the patient's immune status and any infectious processes.
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Which of these snacks will be best for the nurse to offer to a patient with burns covering 40% total body surface area (TBSA) who is in the acute phase of burn treatment?
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Chocolate milkshake rationale: A patient with a burn injury needs high protein and calorie food intake, and the milkshake is the highest in these nutrients. The other choices are not as nutrient-dense as the milkshake.
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What is the priority nursing assessment when caring for a patient who has just arrived in the emergency department after suffering an electrical burn from exposure to a high-voltage current?
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Extremity movement rationale: All patients with electrical burns should be considered at risk for cervical spine injury, and assessments of extremity movement will provide baseline data. The other assessment data also are necessary but not as essential as determining cervical spine status.
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After an employee spills industrial acids on the arms and legs at work, what is the priority action that the occupational health nurse at the facility should take?
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Flush the burned area with large amounts of water. rationale: With chemical burns, the initial action is to remove the chemical from contact with the skin as quickly as possible. Covering the affected area or placing cool compresses on the area will leave the chemical in contact with the skin. Application of an alkaline solution is not recommended.
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A patient who has burns on the back and chest from a house fire has become agitated and restless 9 hours after being admitted to the hospital. Which action should the nurse take first?
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Use pulse oximetry to check the oxygen saturation. rationale: Agitation in a patient who may have suffered inhalation injury might indicate hypoxemia, and this should be assessed by the nurse first. Administration of morphine may be indicated if the nurse determines that the agitation is caused by pain. Assessing level of consciousness and orientation also is appropriate but not as essential as determining whether the patient is hypoxemic. Reassurance is not helpful to reduce agitation in a hypoxemic patient.
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Which of these actions should the nurse take first when a patient arrives in the emergency department with facial and chest burns caused by a house fire?
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Auscultate the patient's lung sounds. rationale: A patient with facial and chest burns is at risk for inhalation injury, and assessment of airway and breathing is the priority. The other actions will be completed after airway management is assured.
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A patient with extensive electrical burn injuries is admitted to the emergency department. Which of these prescribed interventions should the nurse implement first?
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Place on cardiac monitor. rationale: After an electrical burn, the patient is at risk for fatal dysrhythmias and should be placed on a cardiac monitor. The other actions should be accomplished in the following order: Start two IVs, assess for pain, and apply dressings.
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Six hours after a thermal burn covering 50% of a patient's total body surface area (TBSA), the nurse obtains these data when assessing a patient. What is the priority information to communicate to the health care provider?
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Urine output is 20 mL per hour for the past 2 hours. rationale: The urine output should be at least 0.5 to 1.0 mL/kg/hr during the emergent phase, when the patient is at great risk for hypovolemic shock. The nurse should notify the health care provider because a higher IV fluid rate is needed. BP during the emergent phase should be greater than 90 systolic, and the pulse rate should be less than 120. Serous exudate from the burns is expected during the emergent phase.
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After receiving change-of-shift report, which of these patients should the nurse assess first?
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A patient with smoke inhalation who has wheezes and altered mental status rationale: This patient has evidence of lower airway injury and hypoxemia and should be assessed immediately to determine need for oxygen or intubation. The other patients also should be assessed as rapidly as possible, but they do not have evidence of life-threatening complications.
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Which of these patients is most appropriate for the burn unit charge nurse to assign to an RN staff nurse who has floated from the hospital medical unit?
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A 34-year-old patient who has a weight loss of 15% from admission and requires enteral feedings and parenteral nutrition (PN) rationale: An RN from a medical unit would be familiar with malnutrition and with administration and evaluation of response to enteral feedings and PN. The other patients require burn assessment and care that is more appropriate for staff who regularly care for burned patients.
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The nurse notes a bright red skin color for a patient who was found unconscious from smoke inhalation in a burning house. Which action should the nurse take first?
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Place the patient on 100% oxygen using a non-rebreather mask. rationale: The patient's history and skin color suggest carbon monoxide poisoning, which should be treated by rapidly starting oxygen at 100%. The other actions can be taken after the actions to correct gas exchange.
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Which of these laboratory results requires the most rapid action by the nurse who is caring for a patient who suffered a large burn 48 hours ago?
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Serum potassium 6.2 mEq/L rationale: Hyperkalemia can lead to fatal bradycardia and indicates that the patient requires cardiac monitoring and immediate treatment to lower the potassium level. The other laboratory values also are abnormal and require changes in treatment, but they are not as immediately life threatening as the elevated potassium level.
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The RN observes all of the following actions being taken by a staff nurse who has floated to the unit. Which action requires that the RN intervene?
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The float nurse uses clean latex gloves when applying antibacterial cream to a burn wound. rationale: Sterile gloves should be worn when applying medications or dressings to a burn. Hypothermia is an indicator of possible sepsis, and cultures are appropriate. Nondiabetic patients may require insulin because stress and high calorie intake may lead to temporary hyperglycemia. Fentanyl peaks 5 minutes after IV administration and should be used just before and during dressing changes for pain management.
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Which of these nursing actions should be done first for a patient who has suffered a burn injury while working on an electrical power line?
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Stabilize the cervical spine. rationale: Cervical spine injuries are commonly associated with electrical burns. Therefore stabilization of the cervical spine takes precedence after airway management. The other actions also are included in the emergent care after electrical burns, but the most important action is to avoid spinal cord injury.
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A 70 kg patient with burns over 30% of total body surface area (TBSA) is admitted to the burn unit. Using the Parkland formula, calculate the volume of lactated Ringer's solution that the nursing staff will administer during the first 24 hours. _____________
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8400 mL rationale: The Parkland formula states that patients should receive 4 mL/kg/%TBSA burned during the first 24 hours.
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The nurse is estimating the extent of a burn using the rule of nines for a patient who has been admitted with deep partial-thickness burns of the posterior trunk and right arm. What percentage of the patient's total body surface area (TBSA) has been injured? __________________
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27% rationale: When using the rule of nines, the posterior trunk is considered to cover 18% of the patient's body and each arm is 9%.
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In which order will the nurse take these actions when doing a dressing change for a partial-thickness burn wound on a patient's back? Put a comma and space between each answer choice _____________
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d) Administer IV fentanyl (Sublimaze). e) Clean wound with saline-soaked gauze. c) Apply silver sulfadiazine cream. a) Apply sterile gauze dressing. b) Document wound appearance. rationale: Since partial-thickness burns are very painful, the nurse's first action should be to administer pain medications. The wound will then be cleaned, antibacterial cream applied, and covered with a new sterile dressing. The last action should be to document the appearance of the wound.
