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BURNS,MED SURG AND ANSWERS LATEST VERSION
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A 25-year-old patient is admitted with partial-thickness injuries over 20% of the total body surface area involving both lower legs. The nurse would classify this injury as being which of the following?
- a moderate burn
- a minor burn
- a major burn
- a severe burn
- an intermediate burn - ansCorrect Answer: 1 Rationale 1: A moderate burn is a partial-thickness injury that is between 15%-25% of total body surface area in adults. A 70-year-old patient has experienced a sunburn over much of the body. What self-care technique is MOST important to emphasize to an older adult in dealing with the effects of the sunburn?
- increasing fluid intake
- applying mild lotions
- taking mild analgesics
- maintaining warmth
- using sunscreen - ansCorrect Answer: 1 Rationale: Older adults are especially prone to dehydration; therefore, increasing fluid intake is especially important. Other manifestations could include nausea and vomiting. All the measures help alleviate the manifestations of this minor burn which include pain, skin redness, chills, and headache. Use of sunscreen is a preventative, not a treatment measure. A female patient comes into the clinic complaining of nausea and vomiting after spending the weekend at a seaside resort. Which of the following should be the most important assessment for the nurse?
- normal rest and sleep pattern
- typical meal pattern
- if the patient had to change time zones when traveling to the resort
- if the patient has been sunburned - ansCorrect Answer: 4 Rationale: Sunburns result from exposure to ultraviolet light. Because the skin remains intact, the manifestations in most cases are mild and are limited to pain, nausea, vomiting, skin redness, chills, and
BURNS,MED SURG AND ANSWERS LATEST VERSION
GRADED A+
headache. The patient has not reported concerns which will support issues with sleep pattern, diet, and travel. A nurse is caring for a patient who has burns of the ears, head, neck, and right arm and hand. The nurse should place the patient in which position? a. Place the right arm and hand flexed in a position of comfort. b. Elevate the right arm and hand on pillows and extend the fingers. c. Assist the patient to a supine position with a small pillow under the head. d. Position the patient in a side-lying position with rolled towel under the neck. - ansANS: B 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 for the head because this will put pressure on the ears, and the pillow may stick to the ears. Patients with neck burns should not use a pillow because the head should be maintained in an extended position in order to avoid contractures. A nurse is caring for a patient with second- and third-degree burns to 50% of the body. The nurse prepares fluid resuscitation based on knowledge of the Parkland (Baxter) formula that includes which recommendation? A. The total 24-hour fluid requirement should be administered in the first 8 hours. B. One half of the total 24-hour fluid requirement should be administered in the first 8 hours. C. One third of the total 24-hour fluid requirement should be administered in the first 4 hours. D. One half of the total 24-hour fluid requirement should be administered in the first 4 hours. - ansB. One half of the total 24-hour fluid requirement should be administered in the first 8 hours. Fluid resuscitation with the Parkland (Baxter) formula recommends that one half of the total fluid requirement should be administered in the first 8 hours, one quarter of total fluid requirement should be administered in the second 8 hours, and one quarter of total fluid requirement should be administered in the third 8 hours. A nurse is teaching a class of older adults at a senior center about household cleaning agents that may cause burns. Which agents should be included in these instructions?
BURNS,MED SURG AND ANSWERS LATEST VERSION
GRADED A+
Rationale: The severity of electrical burns depends on the type and duration of the current and amount of voltage. Location is not important in determining possible severity. Location is not important in determining possible severity. A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first? a. Auscultate the patient's lung sounds. b. Determine the extent and depth of the burns. c. Infuse the ordered lactated Ringer's solution. d. Administer the ordered hydromorphone (Dilaudid). - ansANS: A 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. A patient comes into the clinic to be seen for a burn that appears moist with blisters. The nurse realizes that this patient most likely has experienced which of the following?
- first-degree burn
- superficial second-degree burn
- deep second-degree burn
- third-degree burn - ansCorrect Answer: 2 Rationale: Partial-thickness, or second-degree, burns can either be superficial or deep. This patient's burn, which appears moist with blisters, is consistent with a superficial second-degree burn. A first- degree burn would involve only the surface layer of skin. Redness would be expected. Deep second- degree and third-degree burns would be deeper and involve more damage to the dermis, epidermis, and underlying tissue. A patient comes into the emergency department with a chemical burn from contact with lye.Assessment and treatment of this patient will be based on what knowledge regarding this type of burn? (Select all that apply)
- This is an alkali burn.
- This type of burn tends to be deeper.
- This is an acid burn.
BURNS,MED SURG AND ANSWERS LATEST VERSION
GRADED A+
- This type of burn will be easier to neutralize.
- This type of burn tends to be more superficial. - ansCorrect Answer: 1, Rationale: This is an alkali burn which is more difficult to neutralize than an acid burn and tends to have a deeper penetration and be more severe than a burn caused by an acid. A patient comes into the physician's office after sustaining chemical burns to the left side of his face and right wrist. The nurse realizes that this patient needs to be treated
- in the outpatient ambulatory clinic.
- in the emergency department.
- in a burn center.
- in the doctor's office and then at home. - ansCorrect Answer: 3 Rationale: Adult patients who should be treated at burn centers include those with burns that involve the hands, feet, face, eyes, ears, or perineum. Patients having small or noninvasive burns may be managed at an outpatient clinic are mild in nature. The emergency department is a location for evaluation of a burn. The physician's office like the ambulatory clinic can manage mild burns. A patient has 25% TBSA burned from a car fire. His wounds have been debrided and covered with a silver-impregnated dressing. The nurse's priority intervention for wound care would be to: a. reapply a new dressing without disturbing the wound bed b. observe the wound for signs of infection during dressing changes c. apply cool compresses for pain relief in between dressing changes d. wash the wound aggressively with soap and water three times a day. - ansCorrect answer: b Rationale: Infection is the most serious threat with regard to further tissue injury and possible sepsis. A patient has a scald burn on the arm that is bright red, moist, and has several blisters. The nurse would classify this burn as which of the following? Select all that apply.
- a superficial partial-thickness burn
- a thermal burn
BURNS,MED SURG AND ANSWERS LATEST VERSION
GRADED A+
A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain adequate nutrition, the nurse should plan to take which action? a. Insert a feeding tube and initiate enteral feedings. b. Infuse total parenteral nutrition via a central catheter. c. Encourage an oral intake of at least 5000 kcal per day. d. Administer multiple vitamins and minerals in the IV solution. - ansANS: A 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. A patient has sustained a partial-thickness injury of 28% of total body surface area (TBSA) and full- thickness injury of 30% or greater of TBSA. How should the nurse classify this burn injury?
- major
- moderate
- minor
- superficial
- intermediate - ansCorrect Answer: 1 Rationale 1: Partial-thickness injuries of greater than 25% of total body surface area in adults and full- thickness injuries 10% or greater of TBSA are considered major burns. A patient is admitted to the burn center with burns of his head and neck, chest, and back after an explosion in his garage. On assessment, the nurse auscultates wheezes throughout the lung fields. On reassessment, the wheezes are gone and the breath sounds are greatly diminished. Which action is the most appropriate for the nurse to take next? a. obtain vital signs and a STAT ABG b. encourage the patient to cough and auscultate the lungs again c. document the findings and continue to monitor the patient's breathing
BURNS,MED SURG AND ANSWERS LATEST VERSION
GRADED A+
d. anticipate the need for endotracheal intubation and notify the physician - ansCorrect answer: d Rationale: Inhalation injury results in exposure of the respiratory tract to intense heat or flames with inhalation of noxious chemicals, smoke, or carbon monoxide. The nurse should anticipate the need for intubation and mechanical ventilation because this patient is demonstrating signs of severe respiratory distress. 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? a. Encourage the patient to cough and auscultate the lungs again. b. Notify the health care provider and prepare for endotracheal intubation. c. Document the results and continue to monitor the patient's respiratory rate. d. Reposition the patient in high-Fowler's position and reassess breath sounds. - ansANS: B 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 is admitted to the emergency department with deep partial-thickness burns over 35 % of the body. What IV solution will be started initially?
- warmed lactated Ringer's solution
- dextrose 5% with saline solution
- dextrose 5% with water
- normal saline solution
- 0.45% saline solution - ansCorrect Answer: 1 Rationale: Warmed lactated Ringer's solution is the IV solution of choice because it most closely approximates the body's extracellular fluid composition. It is warmed to prevent hypothermia.
BURNS,MED SURG AND ANSWERS LATEST VERSION
GRADED A+
A patient is admitted with second- and third-degree burns covering the face, entire right upper extremity, and the right anterior trunk area. Using the rule of nines, what should the nurse calculate the extent of these burns as being? A. 18% B. 22.5% C. 27% D. 36% - ansB. 22.5% Using the rule of nines, for these second- and third-degree burns, the face encompasses 4.5% of the body area, the entire right arm encompasses 9% of the body area, and the entire anterior trunk encompasses 18% of the body area. Since the patient has burns on only the right side of the anterior trunk, the nurse would assess that burn as encompassing half of the 18%, or 9%. Therefore adding the three areas together (4.5 + 9 + 9), the nurse would correctly calculate the extent of this patient's burns to cover approximately 22.5% of the total body surface area. A patient is being discharged after treatment for a scald burn that caused a superficial burn over one hand and a superficial partial-thickness burn on several fingers. What should be included in this patient's discharge instructions? (Select all that apply)
- Report any fever to your healthcare provider.
- Report development of purulent drainage to your healthcare provider.
- Use only sterile dressings on the fingers.
- Cleanse the areas every hour with alcohol to prevent infection.
- Apply the topical antimicrobial agent as instructed. - ansCorrect Answer: 1,2, Rationale: Fever or purulent drainage are indicative of development of infection and should be reported to the healthcare provider. Sterile dressings only should be used on the areas of the superficial partial- thickness burns where the skin is not intact. Cleansing is necessary no more often than daily to the intact skin areas and only soap and water should be used, not alcohol. Topical agents may be ordered by the health care provider and the patient should follow directions for applying to help prevent infection of the areas.
BURNS,MED SURG AND ANSWERS LATEST VERSION
GRADED A+
A patient is being evaluated after experiencing severe burns to his torso and upper extremities. The nurse notes edema at the burned areas. Which of the following best describes the underlying cause for this assessment finding?
- inability of the damaged capillaries to maintain fluids in the cell walls
- reduced vascular permeability at the site of the burned area
- decreased osmotic pressure in the burned tissue
- increased fluids in the extracellular compartment
- the IV fluid being administered too quickly - ansCorrect Answer: 1 Rationale: Burn shock occurs during the first 24-36 hours after the injury. During this period, there is an increase in microvascular permeability at the burn site. The osmotic pressure is increased, causing fluid accumulation. There is a reduction of fluids in the extracellular body compartments. Manifestations of fluid volume overload would be systemic, not localized to the burn areas. A patient is brought to the emergency department with the following burn injuries: a blistered and reddened anterior trunk, reddened lower back, and pale, waxy anterior right arm. Calculate the extent of the burn injury (TBSA) using the rule of nines. - ansCorrect Answer: 22. Rationale : The anterior trunk has superficial partial-thickness burns and is calculated in TBSA as 18%. The arm has a deep partial-thickness burn and is calculated as 4.5%. The burn on the lower back is superficial and is not calculated in TBSA. A patient is coming into the emergency department with third-degree burns over 25% of his body. The nurse should prepare which of the following solutions for intravenous infusion for this patient?
- warmed lactated Ringer's
- 5% dextrose in water
- 5% dextrose in 0.45 normal saline
- 5% dextrose in normal saline - ansCorrect Answer: 1 Rationale: Warmed Ringer's lactate solution is the intravenous fluid most widely used during the first 24 hours after a burn injury because it most closely approximates the body's extracellular fluid composition. A patient is recovering from second- and third-degree burns over 30% of his body and is now ready for discharge. The first action the nurse should take when meeting with the patient would be to:
BURNS,MED SURG AND ANSWERS LATEST VERSION
GRADED A+
- The amount of urine output will be greatest in the first 24 hours after the burn injury.
- The amount of urine will be reduced during the first eight hours of the burn injury and will then increase as the diuresis begins.
- The amount of urine will be elevated due to the amount of intravenous fluids administered during the initial phases of treatment.
- The amount of urine is expected to be decreased for three to five days. - ansCorrect Answer: 1 Rationale: The patient will have an initial reduction in urinary output. Fluid is reduced in the initial phases as the body manages the insult caused by the injury and fluids are drawn into the interstitial spaces. After the shock period passes, the patient will enter a period of diuresis. The diuresis begins between 24 and 36 hours after the burn injury. A patient recovering from a major burn injury is complaining of pain. Which of the following medications will be most therapeutic to the patient?
- morphine 4 mg IV every 5 minutes
- morphine 10 mg IM ever 3-4 hours
- meperidine 75 mg IM every 3-4 hours
- meperidine 50 mg PO every 3-4 hours
- fentanyl citrate (Duragesic) 75 mcg patch every 3 days - ansCorrect Answer: 1 Rationale: Morphine is preferred over meperidine for the burn-injured patient. Typical dose of morphine is 3-5 mg every 5-10 minutes for an adult. The intravenous route is preferred over oral and intramuscular routes. A transdermal patch would not be used because of decreased absorption of the medication through the skin of the burn-injured patient. A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital. Which action should the nurse take first? a. Stay at the bedside and reassure the patient. b. Administer the ordered morphine sulfate IV. c. Assess orientation and level of consciousness. d. Use pulse oximetry to check the oxygen saturation. - ansANS: D Agitation in a patient who may have suffered inhalation injury might indicate hypoxia, and this should be assessed by the nurse first. Administration of morphine may be indicated if the nurse determines that
BURNS,MED SURG AND ANSWERS LATEST VERSION
GRADED A+
the agitation is caused by pain. Assessing level of consciousness and orientation is also appropriate but not as essential as determining whether the patient is hypoxemic. Reassurance is not helpful to reduce agitation in a hypoxemic patient A patient who is being treated with topical mafenide acetate for third-degree burns is demonstrating facial and neck edema. The nurse realizes that this patient most likely
- is developing a hypersensitivity to the medication.
- is reacting positively to the medication.
- needs an increase in dosage of the medication.
- is not responding to the medication. - ansCorrect Answer: 1 Rationale: Approximately 3%-5% of patients develop a hypersensitivity to mafenide, which can manifest as facial edema. The manifestation of facial and neck edema is considered an adverse reaction. There is inadequate information presented to assess response to the medication. A patient who was found unconscious in a burning house is brought to the emergency department by ambulance. The nurse notes that the patient's skin color is bright red. Which action should the nurse take first? a. Insert two large-bore IV lines. b. Check the patient's orientation. c. Assess for singed nasal hair and dark oral mucous membranes. d. Place the patient on 100% oxygen using a non-rebreather mask. - ansANS: D 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 action to correct gas exchange. A patient with a burn inhalation injury is receiving albuterol (Ventolin) for bronchospasm. What is the most important adverse effect of this medication for the nurse to manage? a. GI distress b. tachycardia c. restlessness
BURNS,MED SURG AND ANSWERS LATEST VERSION
GRADED A+
chloride should be monitored. Changing the dressing every two hours is too frequent for the patient. Black discolorations of the skin are anticipated for patients using silver nitrate, and do not highlight a complication of therapy. Silver sulfadiazine, not silver nitrate, administration can result in the development of sulfa crystals in the urine so pushing fluid intake is not an appropriate action for this patient. A patient with burns covering 40% total body surface area (TBSA) is in the acute phase of burn treatment. Which snack would be best for the nurse to offer to this patient? a. Bananas b. Orange gelatin c. Vanilla milkshake d. Whole grain bagel - ansANS: C 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. Gelatin is likely high in sugar. The bagel is a good carbohydrate choice, but low in protein. Bananas are a good source of potassium, but are not high in protein and calories. A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take? a. Notify the health care provider. b. Monitor the pulses every 2 hours. c. Elevate both legs above heart level with pillows. d. Encourage the patient to flex and extend the toes on both feet. - ansANS: A The decrease in pulse in a patient with circumferential burns indicates decreased circulation to the legs and the need for an escharotomy. Monitoring the pulses is not an adequate response to the decrease in circulation. Elevating the legs or increasing toe movement will not improve the patient's circulation A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first? a. Assess oral temperature. b. Check a potassium level.
BURNS,MED SURG AND ANSWERS LATEST VERSION
GRADED A+
c. Place on cardiac monitor. d. Assess for pain at contact points. - ansANS: C After an electrical burn, the patient is at risk for fatal dysrhythmias and should be placed on a cardiac monitor. Assessing the oral temperature is not as important as assessing for cardiac dysrhythmias. Checking the potassium level is important. However, it will take time before the laboratory results are back. The first intervention is to place the patient on a cardiac monitor and assess for dysrhythmias, so that they can be treated if occurring. A decreased or increased potassium level will alert the nurse to the possibility of dysrhythmias. The cardiac monitor will alert the nurse immediately of any dysrhythmias. Assessing for pain is important, but the patient can endure pain until the cardiac monitor is attached. Cardiac dysrhythmias can be lethal. 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? a. 350 mL/hour b. 523 mL/hour c. 938 mL/hour d. 1250 mL/hour - ansANS: C 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. A patient with third-degree burns is being treated with high-volume intravenous fluids and has a urine output of 40 cc per hour. The nurse realizes that this urine output
- is normal for this patient.
- provides evidence that the patient is dehydrated.
- provides evidence that the patient is over-hydrated.
- is indicative of pending renal failure. - ansCorrect Answer: 1 Rationale: Intake and output measurements indicate the adequacy of fluid resuscitation, and should range from 30 to 50 mL per hour in an adult.
BURNS,MED SURG AND ANSWERS LATEST VERSION
GRADED A+
Rationale: The nurse should anticipate this patient's needs for analgesia and administer pain medication to promote the patient's comfort during the exercise session. Arm exercise is not related to the amount of urine in the catheter bag. Linen changes do not impact range of motion activities. The burn's dressing is changed according to the physician's orders or as needed. A patient, experiencing a burn that is pale and waxy with large flat blisters, asks the nurse about the severity of the burn and how long it will take to heal. With which of the following should the nurse respond to this patient?
- The wound is a deep partial-thickness burn, and will take more than three weeks to heal.
- The wound is a partial-thickness burn, and could take up to two weeks to heal.
- The wound is a superficial burn, and will take up to three weeks to heal.
- The wound is a full-thickness burn and will take one to two weeks to heal.
- Wound healing is individualized. - ansCorrect Answer: 1 Rationale: The wound described is a deep partial-thickness burn. Deep partial-thickness wounds will take more than three weeks to heal. A superficial burn is bright red and moist, and might appear glistening with blister formation. The healing time for this type of wound is within 21 days. A full thickness burn involves all layers of the skin and may extend into the underlying tissue. These burns take many weeks to heal. Stating that wound healing is individualized does not answer the patient's question about the severity of the burn. A therapeutic measure used to prevent hypertrophic scarring during rehabilitation phase of burn recover is: a. applying pressure garments b. repositioning the patient every 2 hours c. performing active ROM at least every 4 hours d. massaging the new tissue with water-based moisturizers - ansCorrect answer: a Rationale: Pressure can help keep a scar flat and reduce hypertrophic scarring. Gentle pressure can be maintained on the healed burn with custom-fitted pressure garments.
BURNS,MED SURG AND ANSWERS LATEST VERSION
GRADED A+
A young adult patient who is in the rehabilitation phase 6 months after a severe face and neck burn tells the nurse, "I'm sorry that I'm still alive. My life will never be normal again." Which response by the nurse is best? a. "Most people recover after a burn and feel satisfied with their lives." b. "It's true that your life may be different. What concerns you the most?" c. "It is really too early to know how much your life will be changed by the burn." d. "Why do you feel that way? You will be able to adapt as your recovery progresses." - ansANS: B This response acknowledges the patient's feelings and asks for more assessment data that will help in developing an appropriate plan of care to assist the patient with the emotional response to the burn injury. The other statements are accurate, but do not acknowledge the anxiety and depression that the patient is expressing. A young adult 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 statement by the patient indicates that the problem is resolving? a. "I'm glad the scars are only temporary." b. "I will avoid using a pillow, so my neck will be OK." c. "I bet my boyfriend won't even want to look at me anymore." d. "Do you think dark beige makeup foundation would cover this scar on my cheek?" - ansANS: D 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 An 80-kg patient with burns over 30% of total body surface area (TBSA) is admitted to the burn unit. Using the Parkland formula of 4 mL/kg/%TBSA, what is the IV infusion rate (mL/hour) for lactated Ringer's solution that the nurse will administer during the first 8 hours? - ans600 mL The Parkland formula states that patients should receive 4 mL/kg/%TBSA burned during the first 24 hours. Half of the total volume is given in the first 8 hours and then the last half is given over 16 hours: 4 80 30 = 9600 mL total volume; 9600/2 = 4800 mL in the first 8 hours; 4800 mL/8 hr = 600 mL/hr.
