LA #12 (Burns) Chapter 27 Flashcards Preview

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Flashcards in LA #12 (Burns) Chapter 27 Deck (47)
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1

An employee spilled industrial acids on his arms and legs at work. What is the appropriate action by the occupational nurse at the facility?

a.

Apply cool compresses to the area of exposure.

b.

Apply an alkaline solution to the affected area.

c.

Cover the affected area with dry, sterile dressings.

d.

Flush the substance with large amounts of tap water.

 

    D

If the acid is a dry chemical, it should be brushed from the skin, and then the affected area should be flushed with copious amounts of water to irrigate the skin. This technique is effective when used anywhere from 20 minutes to 2 hours post exposure.

2

A patient is admitted to the emergency department after suffering an electrical burn from exposure to a high-voltage current. In addition to the burn injuries, the nurse should initially assess for the presence of what?

a.

Renal failure

b.

Cerebral edema

c.

Spinal fractures

d.

Metabolic alkalosis

 

    C

Contact with electric current can cause muscle contractions strong enough to fracture the long bones and the vertebrae. Another reason to suspect long bone or spinal fractures is a fall. Most electrical injuries occur when the victim is elevated above the ground and comes in contact with a current source. For this reason, all patients with electrical burns should be considered at risk for a potential cervical spine injury. Cervical spine immobilization should be used during transport and subsequent spinal X-ray films made to rule out any injury.

3

A young woman spilled hot oil from a deep-fat fryer on her right lower leg and foot. Her leg and foot are red and swollen and covered with large blisters. She states that they are very painful. According to burn classification systems, how should the nurse document the burn?

a.

Full-thickness skin destruction

b.

Deep, partial-thickness skin destruction

c.

Superficial, partial-thickness skin destruction

d.

Third degree, with partial-thickness skin destruction

 

    B

A deep, partial-thickness skin destruction gives the appearance of fluid-filled vesicles that are red, shiny, and wet (if vesicles have ruptured). There is also severe pain caused by nerve injury and mild to moderate edema, which is exhibited by this patient.

4

    During the emergent phase of burn injury, the nurse assesses for the presence of hypovolemia. What does the nurse understand is the primary cause of hypovolemia in burn victims?

a.

Major blood loss from injured tissue

b.

Evaporation of fluid from denuded body surfaces

c.

Capillary permeability that causes fluid shift to the interstitium

d.

Third spacing of fluid from the interstitial space into fluid-filled vesicles

 

C

Hypovolemia occurs in burn victims, although fluid is not actually lost from the body as much as it is sequestered in the interstitial spaces and third spaces. As the capillary seal is lost, the interstitial edema fluid is formed.

5

To prevent hypothermia, what is the maximum amount of time a large burn should be cooled?

a.

2 to 3 minutes

b.

5 minutes

c.

10 minutes

d.

20 minutes

 

C

To prevent hypothermia, large burns should be cooled for no more than 10 minutes. Do not immerse the burned body part in cool water because doing so might lead to extensive heat loss.

6

A patient is admitted to the burn unit with burns on his head and neck, chest and back, and left arm and hand following an explosion and fire in his garage. On his admission to the unit, the nurse auscultates wheezes in the patient’s lungs. One hour later, the wheezes cannot be heard, and lung sounds are decreased. What is the most appropriate nursing action at this time?

a.

Place the patient in the high-Fowler’s position.

b.

Encourage the patient to cough, and auscultate the lungs again.

c.

Document the results, and continue to monitor the patient’s progress.

d.

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

 

D

The nurse should anticipate the need for intubation with significant inhalation injury, circumferential full-thickness burns to the neck and chest or a large total body surface area (TBSA) burn, or both, and with decreasing lung sounds. The nurse should notify the physician.

7

    During the early emergent phase of burns, the nurse understands that analgesics should be given intravenously for which of the following reasons?

a.

Absorption of oral or intramuscular drugs is diminished because of impaired circulation.

b.

Analgesics do not need to be administered as frequently when they are given intravenously.

c.

Larger doses of narcotics can be given when administered intravenously than when given intramuscularly.

d.

Respiratory depression is easier to diagnose and treat when narcotics are administered intravenously.

 

A

Early in the postburn period, pain medications should be given intravenously because (1) onset of action is fastest with this route; (2) gastrointestinal function is slowed or impaired as a result of shock or paralytic ileus; and (3) medications injected intramuscularly are not absorbed adequately in burned or edematous areas, and so medications pool in the tissues.

8

A patient with severe burns has fluid replacement ordered using the Parkland formula. The initial rate of administration is 1050 mL/hour. What should the nurse expect the rate of fluid administration to be 18 hours after the burn occurred?

a.

263 mL/hour

b.

350 mL/hour

c.

525 mL/hour

d.

1050 mL/hour

 

C

According to the Parkland formula, during the first 24 hours, half of the volume is to be given during the first 8 hours, then a quarter is given during each of the next 8-hour periods.

9

The nurse determines that fluid replacement for a patient with major electrical burns is adequate based on which of the following findings?

a.

A stable weight

b.

A blood pressure of 90/58 mm Hg

c.

A urinary output of 80 mL/hour

d.

An intake equal to urinary output

 

C

Urinary output is the most commonly used parameter for assessment of adequacy of fluid replacement. The goal for urine output is 0.5 to 1 mL/kg/hour and 75 to 100 mL/hour in patients with electrical burns.

10

Which is an appropriate intervention during the emergent phase of a patient with extensive burns to address the nursing diagnosis of imbalanced nutrition?

a.

An oral intake of 5000 kcal/day

b.

Intravenous administration of multivitamins and minerals

c.

Administration of total parenteral nutrition via a central catheter

d.

Continuous enteral feeding via a feeding tube positioned in the duodenum

 

    D

During the emergent phase of a patient with extensive burns, the nurse should administer enteral feedings to provide nutrition until oral intake can be resumed

11

A patient with deep partial-thickness and full-thickness burns of the face and chest has the wounds treated with the open method. The nurse identifies a nursing diagnosis of risk for infection and an expected patient outcome of absence of wound infections. What is an appropriate nursing intervention to help the patient meet the expected outcome?

a.

Restrict all visitors to prevent cross-contamination of wounds.

b.

Wear gowns, caps, masks, and gloves during all care of the patient.

c.

Use sterile water for cleansing and debridement in the hydrotherapy tank.

d.

Administer prophylactic broad-spectrum antibiotics to prevent bacterial colonization of wounds.

 

B

When the patient’s open burn wounds are exposed, staff must wear personal protective equipment (e.g., disposable hats, masks, gowns, gloves).

12

To prevent contractures in a patient with burns of the head, neck, chest, and right arm and hand, how should the nurse position the patient?

a.

Supine with a pillow under the head and the right arm and hand elevated on a pillow

b.

In a Fowler’s position without a pillow with the right arm and hand extended and elevated on a pillow

c.

Laterally on the left side with a small pillow under the head and the right arm and hand hyperextended

d.

Supine without a pillow and with the right arm and hand flexed in a position of comfort and elevated on pillows

 

    B

The patient should be placed in a high-Fowler’s position unless contraindicated by a possible spinal injury, in which case, a reverse Trendelenburg’s position may be the position of choice. Hands and arms should be extended and elevated on pillows or in slings to minimize edema.

13

    A patient with burns on the upper thorax and circumferential burns on both arms develops decreased radial pulses and loss of sensation in the fingers. What is the most appropriate nursing action?

a.

Notify the physician because an escharotomy is indicated.

b.

Increase the rate of fluid administration to prevent sludging.

c.

Put the patient’s arms through passive range-of-motion exercises.

d.

Elevate the extremities on pillows and re-evaluate the patient in 30 minutes.

 

A

Circulation to the extremities can be severely impaired by circumferential burns and subsequent edema formation. These processes occlude the blood supply, causing ischemia, paresthesias, necrosis, and, eventually, gangrene. An escharotomy (a scalpel incision through the full-thickness eschar) is frequently performed following transfer to a burn unit to restore circulation to compromised extremities.

14

    Ranitidine (Zantac) is prescribed for a patient with major burns. In teaching the patient about the drug’s purpose, the nurse should explain that it is used to prevent which of the following?

a.

Diarrhea

b.

Constipation

c.

Adynamic ileus

d.

Curling’s ulcer

 

D

Ranitidine is given to decrease the incidence of Curling’s ulcer.

15

A patient is to undergo skin grafting with the use of cultured epithelial autografts (CEAs) as skin replacement for full-thickness burns. The nurse explains to the patient that this treatment involves which of the following?

a.

Shaving a split-thickness layer of the patient’s skin from an unburned area to apply over burn wounds

b.

Growing small specimens of the patient’s skin in sheets, which are grafted as permanent skin coverage

c.

Cultivating skin from a cadaver with epidermal growth factor to temporarily cover burn wounds for 1 to 2 weeks

d.

Exposing animal skin to growth factors that stimulate its proliferation and decrease antigenicity for permanent skin coverage of the wound

 

B

CEA is a method of obtaining permanent skin from a person with limited available skin for harvesting. CEA is grown from biopsy specimens obtained from the patient’s own unburned skin.

16

A patient with burns has the nursing diagnosis of pain related to lack of knowledge of pain control methods. What is an appropriate nursing intervention for this problem?

a.

Request that the physician order a patient-controlled analgesia machine for the patient.

b.

Administer pain medications on a routine basis so that the pain does not become out of control.

c.

Teach the patient how to use ordered analgesics with adjunctive methods, such as guided imagery and relaxation.

d.

Use sedative or amnesic drugs in combination with narcotics to reduce the perception of the pain experience.

 

C

The timing and use of analgesics are important for the nurse to teach patients to assist them in pain control. Pharmacological and nonpharmacological pain management techniques are to be used. These techniques are considered adjuncts to traditional pharmacological treatments of pain (e.g., distraction, music therapy, virtual reality). They are not meant to be used exclusively to control pain in the patient with burn injury.

17

    A common nursing diagnosis for the patient with burns is situational low self-esteem. When would the nurse evaluate that patient outcomes for this nursing diagnosis are met?

a.

When the patient sets realistic goals regarding future lifestyle

b.

When the patient accepts the need for psychiatric intervention

c.

When the patient is interested in learning to care for wounds at home

d.

When the patient expresses that the effects of the burn are not important

 

A

Burn survivors and their families remark on the powerful learning experience of the burn and a renewed appreciation of life, despite the ongoing challenges of a prolonged and challenging recovery. Acknowledgement that their many feelings are real and valid can be therapeutic for patients and their families as burn survivors seek to incorporate this life event into their view of themselves and the life they had imagined. Setting realistic goals regarding their future lifestyle is a positive outcome goal.

18

Which of the following burn victims should the nurse assess for carbon monoxide inhalation?

a.

Was found unconscious in a burning building

b.

Has facial burns, hoarseness, and sooty sputum

c.

Inhaled a large amount of steam released by a radiator

d.

Was burned in a charcoal grill fire ignited with gasoline

 

    A

Often the victims of fires, especially those who have been trapped in a closed space, will have elevated carboxyhemoglobin levels; therefore, a patient who was found unconscious in a burning building should be assessed for carbon monoxide levels.

19

When does the nurse recognize that the patient with a burn injury moves from the emergent phase to the acute phase?

a.

When inflammatory symptoms subside

b.

When the burn area is completely covered

c.

When granulation tissue forms in the wounds

d.

When diuresis occurs with low urine specific gravity

 

    D

The emergent phase ends when fluid mobilization and diuresis begin.

20

    Which of the following laboratory results should the nurse monitor closely in the patient during the acute phase of burn injury?

a.

Hematocrit and serum sodium

b.

Serum albumin and hematocrit

c.

Serum potassium and hematocrit

d.

Serum sodium and serum potassium

 

    D

Sodium and potassium are involved in electrolyte shifts; therefore, sodium and potassium must be monitored closely during the acute phase of the burn injury. Sodium rapidly shifts to the interstitial spaces and remains there until edema formation ceases (see Figure 27-6). A potassium shift develops initially because injured cells and hemolyzed red blood cells release potassium into the extracellular spaces.

21

Which of the following injuries is most often chemically produced?

a.

Carbon monoxide poisoning

b.

Inhalation injury below the glottis

c.

Alkali burn

d.

Circumferential chest burn

 

B

An inhalation injury below the glottis is usually chemically produced.

22

Which of the following is considered the most accurate guide for determining the total body surface area affected by a burn?

a.

Rule-of-nines chart

b.

Lund-Browder chart

c.

Sage burn diagram

d.

Burn injury depth classification

    B

The Lund-Browder chart is considered more accurate because the patient’s age, in proportion to relative body-area size, is taken into account.

23

According to the rule-of-nines chart, what percentage of TBSA is affected when the patient has burns to both of his legs and his right arm?

a.

18%

b.

22.5%

c.

27%

d.

31.5%

 

B

According to the rule-of-nines chart, this patient would have a TBSA of 22.5%: 9% for each leg and 4.5% for one arm.

24

With chemical burns, the nurse knows that tissue destruction can continue for up to how many hours after the initial burn?

a.

12

b.

24

c.

48

d.

72

 

D

Chemical burns can continue to destroy tissue for up to 72 hours following the initial burn.

25

After a patient has undergone a rhinoplasty, which nursing intervention will be included in the plan of care?

a.

Educate the patient about how to safely remove and reapply nasal packing.

b.

Reassure the patient that the nose will look normal when the swelling subsides.

c.

Instruct the patient to keep the head elevated for 48 hours to minimize swelling and pain.

d.

Teach the patient to use nonsteroidal anti-inflammatory drugs (NSAIDs) for pain control.

    C

Maintaining the head in an elevated position will decrease the amount of nasal swelling. NSAIDs increase the risk for postoperative bleeding and should not be used postoperatively. The patient would not be taught to remove or reapply nasal packing, which is usually removed by the surgeon on the day after surgery. Although return to a preinjury appearance is the goal of the surgery, it is not always possible to achieve this result.

26

    When teaching the patient with allergic rhinitis about management of the condition, the nurse explains that

a.

over-the-counter (OTC) antihistamines cause sedation, so prescription antihistamines are usually ordered.

b.

corticosteroid nasal sprays will reduce inflammation, but systemic effects limit their use.

c.

use of oral antihistamines for a few weeks before the allergy season may prevent reactions.

d.

identification and avoidance of environmental triggers are the best way to avoid symptoms.

 

D

The most important intervention is to assist the patient in identifying and avoiding potential allergens. Intranasal corticosteroids (not oral antihistamines) should be started several weeks before the allergy season. Corticosteroid nasal sprays have minimal systemic absorption. Nonsedating antihistamines are available OTC.

27

After discussing management of upper respiratory infections (URI) with a patient who has acute viral rhinitis, the nurse determines that additional teaching is needed when the patient says

a.

“I can take acetaminophen (Tylenol) to treat discomfort.”

b.

“I will drink lots of juices and other fluids to stay hydrated.”

c.

“I can use my nasal decongestant spray until the congestion is all gone.”

d.

“I will watch for changes in nasal secretions or the sputum that I cough up.”

 

    C

The nurse should clarify that nasal decongestant sprays should be used for no more than 3 days to prevent rebound vasodilation and congestion. The other responses indicate that the teaching has been effective.

28

An RN is observing a nursing student who is suctioning a hospitalized patient with a tracheostomy in place. Which action by the student requires the RN to intervene?

a.

The student preoxygenates the patient for 1 minute before suctioning.

b.

The student puts on clean gloves and uses a sterile catheter to suction.

c.

The student inserts the catheter about 5 inches into the tracheostomy tube.

d.

The student applies suction for 10 seconds while withdrawing the catheter.

 

    B

Sterile gloves and a sterile catheter are used when suctioning a tracheostomy. The other student actions do not require intervention by the RN. Although the patient may not need 1 minute of preoxygenation, this would not be unsafe. Suctioning for 10 seconds is appropriate. The length of catheter that should be inserted depends on the length of the tracheostomy tube, but 5 inches would be appropriate for most adult patients.

29

When the nurse is deflating the cuff of a tracheostomy tube to evaluate the patient’s ability to swallow, it is important to

a.

clean the inner cannula of the tracheostomy tube before deflation.

b.

deflate the cuff during the inhalation phase of the respiratory cycle.

c.

suction the patient’s mouth and trachea before deflation of the cuff.

d.

insert exactly the same volume of air into the cuff during reinflation.

 

    C

The patient’s mouth and trachea should be suctioned before the cuff is deflated to prevent aspiration of oral secretions. The amount of air needed to inflate the cuff varies and is adjusted by measuring cuff pressure or using the minimal leak technique, not by measuring the volume of air removed from the cuff. The cuff is deflated during patient exhalation so that secretions will be forced into the mouth rather than aspirated. There is no need to clean the inner cannula before cuff deflation.

30

    The nurse is caring for a spontaneously breathing patient who has a tracheostomy. To determine that the patient can protect the airway when eating without having the tracheostomy cuff inflated, the nurse will deflate the cuff and

a.

ask the patient to say a few sentences.

b.

monitor for signs of respiratory distress.

c.

have the patient drink a small amount of grape juice and observe for coughing.

d.

auscultate the lungs for crackles after having the patient take a few sips of water.

 

C

Assessing the ability of the patient to drink a colored fluid, such as grape juice, will provide evidence that the patient will not aspirate. Even if the patient is able to talk, aspiration may occur. Because the patient is already breathing spontaneously, deflating the cuff would not cause respiratory distress. Crackles are not present immediately after aspiration, since the inflammatory process takes time to occur.