Chapter 55

Question 1

The nurse is at the scene of a fire caring for a patient with a thermal burn on the face, chest, and abdomen. What action should the nurse perform first?

Answer 1

Ensure an open airway.

Question 2

The nurse is caring for a patient with burns covering the entire surface of both arms and the anterior trunk. Approximately what percentage of the patient’s body surface area has been affected?

Answer 2

36

Question 3

The nurse is caring for a patient in the initial phase of treatment for a partial-thickness burn. The patient has been stabilized, with blood pressure 140/88 mm Hg, pulse 78 beats/min, respirations 22 breaths/min, and temperature 97.4°F (36.3°C). Which new assessment finding should be immediately communicated to the health care provider (HCP)?

Answer 3

122/74

Question 4

The nurse is caring for a patient who is 2 days post-inhalation burn injury from a house fire. Which outcome best indicates that nursing interventions for impaired gas exchange have been effective?

Answer 4

The patient is alert and oriented

Question 5

A patient is having a surgical procedure done to promote peripheral tissue perfusion in an extremity with full-thickness circumferential burns. What term should the nurse use to document this procedure?

Answer 5

Escharotomy

Question 6

The nurse is caring for a patient who is receiving fluid replacement after being burned on 37% of the body. Nursing assessment reveals a blood pressure of 80/60 mm Hg, heart rate of 120 beats/min, and urine output of 10 mL over the past hour. After reporting these findings, which order should the nurse expect to be prescribed for this patient?

Answer 6

Increase IV fluid

Question 7

The nurse is providing wound care to a patient’s skin graft donor sites used for burn treatment. For which type of wound is this nurse providing care?

Answer 7

Partial thickness

Question 8

The nurse is caring for a patient admitted to the burn unit with burns to 45% of the body. After 3 days, the nurse notes that the patient’s temperature is newly elevated at 100.2°F (37.9°C), and the patient exhibits new-onset agitation and confusion. What should the nurse do first?

Answer 8

Notify RN

Question 9

A patient is admitted to the emergency department with chemical burns to the chest and abdomen. The RN immediately begins a sterile saline lavage. What should the licensed practical nurse (LPN) do to assist during this procedure?

Answer 9

Remove patient clothing

Question 10

The nurse is caring for a patient 3 days following a split-thickness burn injury from a fire. Which observation indicates that nursing interventions to promote cardiac output have been effective?

Answer 10

Bp 128/66

Question 11

A patient is diagnosed with superficial partial-thickness burns. How many days should the nurse instruct the patient that these burns will need to heal?

Answer 11

7-10

Question 12

A patient has burns on both legs and in the genital/perineum area. What is this patient’s percentage of burned area?

Answer 12

37%

Question 13

A patient wants to know how long it will take to know if a skin graft used to cover a burn site is successful. How many days should the nurse explain as needed for graft vascularization to occur?

Answer 13

3 to 5

Question 14

The nurse notes that a patient with full thickness burns has an increase in hematocrit level. What should the nurse realize is causing this change in laboratory value?

Answer 14

Loss of intravascular fluid

Question 15

A patient with a deep partial thickness burn is prescribed wet to dry gauze dressings. Which type of debridement is the nurse performing with this dressing?

Answer 15

Mechanical

Question 16

The nurse is caring for a patient who sustained a partial-thickness burn to the face. Which assessment findings should the nurse expect? (Select all that apply.)

Answer 16

Blisters
Bright red color
Blanching

Question 17

The nurse is assisting with the care of a patient admitted to the emergency department with chemical burns across the chest and hands. Which actions should be included in the plan of care? (Select all that apply.)

Answer 17

Remove all contaminated clothing.
Cover the patient with a clean sheet.
Obtain a history of the event and burning agent.
Provide copious tepid water lavage for 20 minutes.

Question 18

The nurse is caring for a patient with extensive burns. For which systemic responses to the burn should the nurse monitor the patient? (Select all that apply.)

Answer 18

Hypovolemia
Peptic ulceration
Increased oxygen consumption
Depression of immunoglobulins

Question 19

The nurse is preparing a patient with 46% total body surface area burned for graft placement. Which anatomical locations should the nurse expect to have a lower rate of graft success than other areas of the body? (Select all that apply.

Answer 19

Axillae
Buttocks
Perineum

Joint areas

Question 20

A victim of a fire in a manufacturing plant is brought to the emergency department. The HCP suspects this victim has sustained an inhalation injury. Which tests should the nurse expect to be prescribed for this patient? (Select all that apply.)

Answer 20

Bronchoscopy

Arterial blood gases
Carboxyhemoglobin level

Question 21

The nurse is preparing to apply dressings to a patient’s partial-thickness burn wounds. What should the nurse keep in mind when applying these dressings? (Select all that apply.)

Answer 21

Elevate affected extremities.

Limit the amount of dressing bulk.

Wrap extremities from distal to proximal.

Question 22

A patient with a partial thickness burn wound is prescribed synthetic dressings. What should the nurse explain to the patient about this type of dressing? (Select all that apply.)

Answer 22

Easier to store
Cost less to use
Readily available
Come in various shapes