Burns (chapter 21)

Question 1

The optimal measurement of intravascular fluid status during the immediate fluid resuscitation phase of burn treatment is:

a. blood urea nitrogen.
b. daily weight.
c. hourly intake and urine output.
d. serum potassium.

Answer 1

c. hourly intake and urine output.

Question 2

In patients with extensive burns, edema occurs in both burned and unburned areas because of:
A.catecholamine-induced vasoconstriction.
B. decreased glomerular filtration.
C. increased capillary permeability.
D. loss of integument barrier.

Answer 2

increased capillary permeability

Question 3

Tissue damage from burn injury activates an inflammatory response that increases the patients risk for:
A.acute kidney injury.
B.acute respiratory distress syndrome.
C. infection.
D. stress ulcers.

Answer 3

C. infection

Question 4

The nurse is caring for a burn-injured patient who weighs 154 pounds, and the burn injury covers 50% of his body surface area. The nurse calculates the fluid needs for the first 24 hours after a burn injury using a standard fluid resuscitation formula of 4 mL/kg/% burn of intravenous (IV) fluid for the first 24 hours. The nurse plans to administer what amount of fluid in the first 24 hours?

a. 2800 mL
b. 7000 mL
c. 14 L
d. 28 L

Answer 4

c. 14 L

Question 5

The nurse is caring for a patient who has circumferential full-thickness burns of his forearm? A priority in the plan of care is :

a. Keeping the extremity in a dependent position
b. Active and passive range of motion every hour.
c. Preparing for an escharotomy as a prophylactic measure d. Splinting the forearm

Answer 5

b. Active and passive range of motion every hour.

Question 6

The patient asks the nurse if the placement of the autograft over his full-thickness burn will be the only surgical intervention needed to close his wound. The nurses best response would be:

a. Unfortunately, an autograft skin is a temporary graft and a second surgery will be needed to close the wound.
b. An autograft is a biological dressing that will eventually be replaced by your body generating new tissue.
c. Yes, an autograft will transfer your own skin from one area of your body to cover the burn wound.
d. Unfortunately, autografts frequently do not adhere well to burn wounds and a xenograft will be necessary to close the wound.

Answer 6

c. Yes, an autograft will transfer your own skin from one area of your body to cover the burn wound.

Question 7

A patient admitted with severe burns to his face and hands is showing signs of extreme agitation. The nurse should explore the mechanism of burn injury possibly related to:

a. excessive alcohol use.
b. methamphetamine use.
c. posttraumatic stress disorder. d. subacute delirium.

Answer 7

b. methamphetamine use.

Question 8

The nurse is caring for patient who has been struck by lightning. Because of the nature of the injury, the nurse assesses the patient for which of the following?

a. Central nervous system deficits
b. Contractures
c. Infection
d. Stress ulcers

Answer 8

a. Central nervous system deficits

Question 9

The nurse is providing care to manage the pain of a patient with burns. The physician has ordered opiates to be given intramuscularly. The nurse contacts the physician to change the order to intravenous administration because:

a. intramuscular injections cause additional skin disruption.
b. burn pain is so severe it requires relief by the fastest route available.
c. hypermetabolism limits effectiveness of medications administered intramuscularly.
d. tissue edema may interfere with drug absorption of injectable routes.

Answer 9

d. tissue edema may interfere with drug absorption of injectable routes.

Question 10

When paramedics notice singed hairs in the nose of a burn patient, it is recommended that the patient be intubated. What is the reasoning for the immediate intubation?

a. Carbon monoxide poisoning always occurs when soot is visible.
b. Inhalation injury above the glottis may cause significant edema that obstructs the airway.
c. The patient will have a copious amount of mucus that will need to be suctioned.
d. The singed hairs and soot in the nostrils will cause dysfunction of cilia in the airways.

Answer 10

b. Inhalation injury above the glottis may cause significant edema that obstructs the airway.

Question 11

A patient with a 60% burn in the acute phase of treatment develops a tense abdomen, decreasing urine output, hypercapnia, and hypoxemia. Based on this assessment, the nurse anticipates interventions to evaluate and treat the patient for:

a. acute kidney injury.
b. acute respiratory distress syndrome.
c. intraabdominal hypertension.
d. disseminated intravascular coagulation disorder.

Answer 11

c. intraabdominal hypertension.

Question 12

An elderly individual from an assisted living facility presents with severe scald burns to the buttocks and back of the thighs. The caregiver from the ALF accompanies the patient to the emergency department and states that the bath water was too hot and that the patient sat in the water too long. What should the nurse do?

a. Ask the caregiver at what temperature the water heater is set in the home.
b. Ask the caregiver to step out while examining the patients burn injury.
c. Immediately contact the police to report the suspected elder abuse.
d. Ask the caregiver to describe exactly how the injury occurred.

Answer 12

b. Ask the caregiver to step out while examining the patients burn injury.

Question 13

Silver is used as an ingredient in many burn dressings because it:

a. stimulates tissue granulation.
b. is effective against a wide spectrum of wound pathogens.
c. provides topical pain relief.
d. stimulates wound healing.

Answer 13

b. is effective against a wide spectrum of wound pathogens.

Question 14

The nurse understands that negative-pressure wound therapy may be used in the treatment of partial- thickness burn wounds to do which of the following?

a. Maintain a closed wound system to decrease the risk of infection.
b. Remove excessive wound fluid and promote moist wound healing.
c. Increase patient mobility with large burn wounds.
d. Quantify wound drainage amount for more accurate output assessment.

Answer 14

b. Remove excessive wound fluid and promote moist wound healing.

Question 15

The nurse is caring for a patient with an electrical injury. The nurse understands that patients with electrical injury are at a high risk for acute kidney injury secondary to:

a. hypervolemia from burn resuscitation.
b. increased incidence of ureteral stones.
c. nephrotoxic antibiotics for prevention of infection.
d. release of myoglobin from injured tissues.

Answer 15

d. release of myoglobin from injured tissues.

Question 16

The nurse is caring for a patient with a chemical burn injury. The priority nursing intervention is to:

a. remove the patients clothes and flush the area with water.
b. apply saline compresses.
c. contact a poison control center for directions on neutralizing agents.
d. remove all jewelry.

Answer 16

a. remove the patients clothes and flush the area with water.

Question 17

Patients with burns may have mesh grafts or sheet grafts. Which of the following sites is most likely to have a sheet graft applied?

a. Arm
b. Face
c. Leg
d. Chest

Answer 17

b. Face

Question 18

The nurse is caring for a patient who has undergone skin grafting of the face and arms for burn wound treatment. A primary nursing diagnosis is:

a. altered nutrition, less than body requirements.
b. body image disturbance.
c. decreased cardiac output.
d. fluid volume deficit.

Answer 18

b. body image disturbance.

Question 19

The nurse is assisting the patient to select foods from the menu that will promote wound healing. Which statement indicates the nurses knowledge of nutritional goals?

a. Avoid foods that have saturated fats. Fats interfere with the ability of the burn wound to heal.
b. Choose foods that are high in protein, such as meat, eggs, and beans. These help the burns to heal.
c. It is important to choose foods like bread and pasta that are high in carbohydrates. These foods will give you energy and help you to heal faster.
d. Select foods that have lots of fiber, such as whole grains and fruits. These will promote removal of toxins from the body that interfere with healing.

Answer 19

b. Choose foods that are high in protein, such as meat, eggs, and beans. These help the burns to heal.

Question 20

A burn patient in the rehabilitation phase of injury is increasingly anxious and unable to sleep. The nurse should consult with the provider to further assess the patient for:

a. acute delirium.
b. posttraumatic stress disorder.
c. suicidal intentions.
d. bipolar disorder.

Answer 20

b. posttraumatic stress disorder.

Question 21

The nurse is planning care to meet the patients pain management needs related to burn treatment. The patient is alert, oriented, and follows commands. The pain is worse during the day when various treatments are scheduled. Which statement to the physician best indicates the nurses knowledge of pain management for this patient?

a. Can we ask the music therapist to come by each morning to see if that will help the patients pain?
b. The patients pain is often unrelieved. I suggest that we also add benzodiazepines to the opioids around the clock.
c. The patients pain is often unrelieved. It would be best if we can schedule the opioids around the clock.
d. The patients pain varies depending on the treatment given. Can we try patient-controlled analgesia to see if that helps the patient better?

Answer 21

d. The patients pain varies depending on the treatment given. Can we try patient-controlled analgesia to see if that helps the patient better?

Question 22

The nurse is conducting an admission assessment of an 82-year-old patient who sustained a 12% burn from spilling hot coffee on the hand and arm. Which statement is of priority to assist in planning treatment?

a. Do you live alone?
b. Do you have any drug or food allergies?
c. Do you have a heart condition or heart failure?
d. Have you had any surgeries?

Answer 22

c. Do you have a heart condition or heart failure?

Question 23

A 63-year-old patient is admitted with new onset fever; flulike symptoms; blisters over her arms, chest, and neck; and red, painful, oral mucous membranes. The patient should be further evaluated for which possible nonburn injured skin disorder?

a. Toxic epidermal necrolysis
b. Staphylococcal scalded skin syndrome
c. Necrotizing soft tissue infection
d. Graft versus host disease

Answer 23

a. Toxic epidermal necrolysis

Question 24

A(An) often produces a superficial cutaneous injury but may cause cardiopulmonary arrest and transient but severe central nervous system deficits.

a. chemical burn
b. electrical burn
c. heat burn
d. infection

Answer 24

b. electrical burn

Question 25

Which of the following statements about the pain management of a burn victim are true? (Select all that apply.) a. Additional pain medication may be needed because of rapid body metabolism. b. Pain medication should be given before procedures such as debridement, dressing changes, and physical therapy. c. Patients with a history of drug and alcohol abuse will require higher doses of pain medication. d. The intramuscular route is preferred for pain medication administration.

Answer 25

a. Additional pain medication may be needed because of rapid body metabolism. b. Pain medication should be given before procedures such as debridement, dressing changes, and physical therapy. c. Patients with a history of drug and alcohol abuse will require higher doses of pain medication.

Question 26

Which of the following factors increase the burn patients risk for venous thromboembolism? (Select all that apply.) a. Burn injury less than 10% b. Bedrest c. Burns to lower extremities d. Electrical burn injury e. Delayed fluid resuscitation

Answer 26

b. Bedrest c. Burns to lower extremities e. Delayed fluid resuscitation

Question 27

The nurse is caring for a patient with burns to the hands, feet, and major joints. The nurse plans care to include which of the following? (Select all that apply.) a. Applying splints that maintain the extremity in an extended position b. Implementing passive or active range-of-motion exercises c. Keeping the limbs as immobile as possible d. Wrapping fingers and toes individually with bandages

Answer 27

a. Applying splints that maintain the extremity in an extended position b. Implementing passive or active range-of-motion exercises d. Wrapping fingers and toes individually with bandages

Question 28

Which of the following infection control strategies should the nurse implement to decrease the risk of infection in the burn-injured patient? (Select all that apply.) a. Apply topical antibacterial wound ointments/dressings. b. Change indwelling urinary catheter every 7 days. c. Daily assess the need for central IV catheters. d. Restrict family visitation. e. Maintain strict aseptic technique during burn wound management.

Answer 28

a. Apply topical antibacterial wound ointments/dressings. c. Daily assess the need for central IV catheters. e. Maintain strict aseptic technique during burn wound management.

Question 29

Which complications may manifest after an electrical injury? (Select all that apply.) a. Long bone fractures b. Cardiac dysrhythmias c. Hypertension d. Compartment syndrome of extremities e. Dark brown urine f. Peptic ulcer disease g. Acute cataract formation h. Seizures

Answer 29

a. Long bone fractures b. Cardiac dysrhythmias d. Compartment syndrome of extremities e. Dark brown urine g. Acute cataract formation h. Seizures

Question 30

An autograft is used to optimally treat a partial- or full-thickness wound that: (Select all that apply.) a. involves a joint. b. involves the face, hands, or feet. c. is infected. d. requires more than 2 weeks for healing.

Answer 30

a. involves a joint. b. involves the face, hands, or feet. d. requires more than 2 weeks for healing.

Question 31

The correct priority order of actions in prehospital primary survey for burn injuries is: , , . (Put a comma and space between each answer choice.) a. Assess ABCs and cervical spine. b. Provide oxygen therapy if smoke inhalation is suspected. c. Make rapid head-to-toe assessment to rule out additional trauma. d. Stop the burning process and prevent further injury.

Answer 31

D-A-B-C

Question 32

FYI*

Answer 32

Early care has a positive impact on recovery. The first priority is to stop the burning process and prevent further injury. At this point, you initiate the primary survey, which is to assess the ABCs and cervical spine. Oxygen therapy follows the ABCs. The secondary survey includes further assessment for additional injuries