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3.

When assessing a patient’s full-thickness burn injury during the emergent phase, what would
the nurse expect to find?
a. Leathery, dry, hard skin
b. Red, fluid-filled vesicles
c. Massive edema at the injury site
d. Serous exudate on a shiny, dark brown wound
3. a. Dry, waxy white, leathery, or hard skin is characteristic of
full-thickness burns in the emergent phase and it may turn
brown and dry in the acute phase. Deep partial-thickness
burns in the emergent phase are red and shiny and have
blisters. Edema may not be as extensive in full-thickness
burns because of thrombosed vessels.
3. a. Dry, waxy white, leathery, or hard skin is characteristic of
full-thickness burns in the emergent phase and it may turn
brown and dry in the acute phase. Deep partial-thickness
burns in the emergent phase are red and shiny and have
blisters. Edema may not be as extensive in full-thickness
burns because of thrombosed vessels.

4. A patient has the following mixed deep partial-thickness and full-thickness burn injuries: face,
anterior neck, right
anterior trunk, and anterior surfaces of the right arm and lower leg.
a. According to the Lund-Browder chart, what is the extent of the patient’s burns?
______% total body surface area (TBSA)
b. According to the rule of nines chart, what is the extent of the patient’s burns?
______% TBSA
c. Is it possible to determine the actual extent and depth of burn injury during the emergent
phase of the burn?
Why or why not?
4. a. 3. + 1 + 6. + 2 + 1. + 3. = 18% TBSA
b. 4. + 9 + 4. + 4. = 22.% TBSA
c. No, because edema and inflammation obscure the
demarcation of zones of injury.

8. What is the initial cause of hypovolemia during the emergent phase of burn injury?
a. Increased capillary permeability
b. Loss of sodium to the interstitium
c. Decreased vascular oncotic pressure
d. Fluid loss from denuded skin surfaces
8. a. Although all of the selections add to the hypovolemia
that occurs in the emergent burn phase, the initial and most
pronounced effect is caused by fluid shifts out of the blood
vessels as a result of increased capillary permeability
9. How is the immune system altered in a burn injury?
a. Bone marrow stimulation
b. Increase in immunoglobulin levels
c. Impaired function of white blood cells (WBCs)
d. Overwhelmed by microorganisms entering denuded tissue
9. c. Burn injury causes widespread impairment of the immune
system, with impaired WBC functioning, bone marrow
depression, and a decrease in circulating immunoglobulins,
which allows microorganisms to grow.

11. A patient has a 20% TBSA deep partial-thickness and full-thickness burn to the right anterior
chest and entire right
arm. What is important for a nurse to assess in this patient?
a. Presence of pain
b. Swelling of the arm
c. Formation of eschar
d. Presence of pulses in the arms
11. d. In circumferential burns, circulation to the extremities
can be severely impaired and pulses should be monitored
closely for signs of obstruction by edema. Swelling of the
arms would be expected but it becomes dangerous when it
occludes blood vessels. Pain and eschar are also expected.

12. Which burn patient should have nasotracheal or endotracheal intubation?


a. Carbon monoxide poisoning
b. Electrical burns causing cardiac dysrhythmias
c. Thermal burn injuries to the face, neck, or airway
d. Respiratory distress from eschar formation around the chest
12. c. Patients with major injuries involving burns to the face and
neck require intubation within 1 to 2 hours after burn injury to
prevent the need for emergency tracheostomy, which is done
if symptoms of upper respiratory obstruction occur. Carbon
monoxide poisoning is treated with 100% oxygen and eschar
constriction of the chest is treated with an escharotomy.

13. A patient is admitted to the emergency department at 10:15 pm following a flame burn at
9:30 pm. The patient has
40% TBSA deep partial-thickness and full-thickness burns and weighs 132 lb.
a. According to the Parkland formula, the type of fluid prescribed for the patient would be
____________________
and the total amount to be administered during the first 24 hours would be ______ mL.
b. The schedule for the fluid administration would be mL between
and ___________ (time), ________mL between ___________ and ___________, and ______
mL
between __________ and __________.
c. Colloidal solutions are given in the second 24 hours. Based on the patient’s body weight,
what amount of these
solutions will be given during this time?
d. The adequacy of the patient’s fluid replacement is determined by and
13. To calculate fluid replacement, the patient’s weight in
pounds must be converted to kilograms: 132 lb = 60 kg.
a. lactated Ringer’s solution; 4 mL × 60 × 40 = 9600 mL
b. 4800 mL between 10:15 pm and 5:30 am; 2400 mL
between 5:30 am and 1:30 pm; 2400 mL between 1:30
pm and 9:30 pm
c. 720–1200 mL (0.3–0.5 mL/kg/%/TBSA or 0.3 or
0.5 mL × 60 × 40)
d. urine output (0.5 to 1 mL/kg/hr = 30–50 mL/hr) and
vital signs (systolic BP 90, HR <120 bpm, RR 16–20).

17. How should the nurse position the patient with ear, face, and neck burns?
a. Prone
b. On the side
c. Without pillows
d. With extra padding around the head
17. c. Patients with ear burns are not allowed to use pillows
because of the danger of the burned ear sticking to the
pillowcase and patients with neck burns are not allowed to
use pillows because contractures of the neck can occur.
19. At the end of the emergent phase and the initial acute phase of burn injury, a patient has a
serum sodium level of
152 mEq/L (152 mmol/L) and a serum potassium level of 2.8 mEq/L (2.8 mmol/L). What could
have caused these
imbalances?
a. Free oral water intake
b. Prolonged hydrotherapy
c. Mobilization of fluid and electrolytes in the acute phase
d. Excessive fluid replacement with dextrose in water without potassium supplementation
19. c. At the end of the emergent phase, fluid mobilization
moves potassium back into the cells and sodium returns to
the vascular space, causing hypokalemia and hypernatremia.
As diuresis in the acute phase continues, sodium will be lost
in the urine and potassium will continue to be low unless it
is replaced. Excessive fluid replacement with 5% dextrose
in water without potassium supplementation can cause
hyponatremia with hypokalemia. Prolonged hydrotherapy
and free oral water intake can cause a decrease in both
sodium and potassium.

20. A burn patient has a nursing diagnosis of impaired physical mobility related to a limited
range of motion (ROM)
resulting from pain. What is an appropriate nursing intervention for this patient?
a. Have the patient perform ROM exercises when pain is not present.
b. Provide analgesic medications before physical activity and exercise.
c. Teach the patient the importance of exercise to prevent contractures.
d. Arrange for the physical therapist to encourage exercise during hydrotherapy.
20. b. The limited ROM in this situation is related to the
patient’s inability or reluctance to exercise the joints
because of pain and the appropriate intervention is to help
control the pain so that exercises can be performed. The
patient is probably never without some pain and although
exercises and enlisting the help of the physical therapist
are important, neither of these interventions addresses the
cause.

26. A 24-year-old female patient does not want the wound cleansing and dressing change to
take place. She states,
“What difference will it make anyway?” What will the nurse encourage the patient to do?
a. Have the wound cleaned and the dressing changed
b. Have a snack before having the treatments completed
c. Talk about what is troubling her with the nurse and/or her family
d. Call the chaplain to come and talk to her and convince her to have the care
26. c. There is tremendous psychologic impact with a burn
injury. Open communication with caregivers, close friends,
and the burn team about fears regarding loss of life as she
once knew it, loss of function, temporary or permanent
deformity and disfigurement, return to routine life, financial
burdens, rehabilitation, and her future are all essential.
Simply convincing her to have the wound cared for ignores
her psychologic, emotional, and perhaps spiritual needs.

7) A patient who has been severely burned in an accident is brought to the


emergency department. The physician orders a regimen to begin fluid
resuscitation. Which type of fluid would the nurse most likely use as part of fluid
resuscitation following a burn injury?
Lactated Ringer's solution (Correct Answer)

0.9% Normal saline

D10W
D5 ½ NS with KCl

Rationale
When a patient is severely burned, he requires a significant amount of fluid replacement in the first 24 hours, known
as fluid resuscitation. Lactated Ringer's solution is typically the fluid of choice because it is easy to access, which is
important because the patient will need a lot of fluid. Lactated Ringer's is an isotonic solution that contains a small
amount of electrolytes.

9) A 12-year-old boy has been brought into the emergency room after suffering a
burn injury while helping his dad in the garage. The nurse performs a rapid initial
assessment of the wounds and checks for signs of inhalation injury. Which of the
following signs or symptoms would indicate an inhalation injury in this child?
Elevated carboxyhemoglobin level (Correct Answer)

Burns to the neck and chest

Burned hair and eyebrows

Respiratory rate of 24/min

Rationale
Initial injury occurs when a person breathes in chemicals or certain substances that can burn the airway and
respiratory tract. Inhalation may be more likely to occur with burn injuries, as substances that burn the skin, such as
fire, often release smoke and gases that cause injury when inhaled. Signs or symptoms of an inhalation injury include
coughing, increased mucus production, shortness of breath, chest pain, and singed hairs around the mouth and
nose. The patients carboxyhemoglobin level may also be elevated, indicating exposure to carbon monoxide gas.

10) A triage nurse takes a call from a patient who tells her that he has been
burned while trying to do some electrical wiring. The nurse asks the client for
more information. Which data from the patient would indicate that he has suffered
a 2nd-degree burn?
The skin is dark red, glossy, and has blisters (Correct Answer)

The skin is light red and swollen

The skin is light red with a small amount

The skin is dark, leathery, and dry

Rationale
Minor burns can be cared for at home and are at little risk of infection or complications. If a patient experiences a 2nd
degree burn or worse, he should seek treatment at a healthcare center. A 2nd degree burn involves damage to the
epidermis and part of the dermal layer of skin. It is manifested by skin that is dark red, glossy in appearance, and has
blisters.

1. The newly admitted client has burns on both legs. The burned areas
appear white and leather-like. No blisters or bleeding are present, and
the client states that he or she has little pain. How should this injury be
categorized?
A. Superficial
B. Partial-thickness superficial
C. Partial-thickness deep
D. Full thickness

1. Answer: D

The characteristics of the wound meet the criteria for a full-thickness injury
(color that is black, brown, yellow, white or red; no blisters; pain minimal; outer
layer firm and inelastic).

2. The newly admitted client has a large burned area on the right arm.
The burned area appears red, has blisters, and is very painful. How
should this injury be categorized?

A. Superficial
B. Partial-thickness superficial
C. Partial-thickness deep
D. Full thickness

2. Answer: B

The characteristics of the wound meet the criteria for a superficial


partialthickness injury (color that is pink or red; blisters; pain present and
high).

4. Which vitamin deficiency is most likely to be a long-term


consequence of a full-thickness burn injury?
A. Vitamin A
B. Vitamin B
C. Vitamin C
D. Vitamin D

4. Answer: D

Skin exposed to sunlight activates vitamin D. Partial-thickness burns reduce the


activation of vitamin D. Activation of vitamin D is lost completely in full
thickness burns.

8. What clinical manifestation should alert the nurse to possible carbon


monoxide poisoning in a client who experienced a burn injury during a
house fire?

A. Pulse oximetry reading of 80%


B. Expiratory stridor and nasal flaring
C. Cherry red color to the mucous membranes
D. Presence of carbonaceous particles in the sputum

8. Answer: C

The saturation of hemoglobin molecules with carbon monoxide and the


subsequent vasodilation induces a “cherry red” color of the mucous membranes
in these clients. The other manifestations are associated with inhalation injury,
but not specifically carbon monoxide poisoning.

11. Which type of fluid should the nurse expect to prepare and
administer as fluid resuscitation during the emergent phase of burn
recovery?
A. Colloids
B. Crystalloids
C. Fresh-frozen plasma
D. Packed red blood cells

11. Answer: B

Although not universally true, most fluid resuscitation for burn injuries starts
with crystalloid solutions, such as normal saline and Ringer’s lactate. The burn
client rarely requires blood during the emergent phase unless the burn is
complicated by another injury that involved hemorrhage. Colloids
and plasma are not generally used during the fluid shift phase because these
large particles pass through the leaky capillaries into the interstitial fluid, where
they increase the osmotic pressure. Increased osmotic pressure in the
interstitial fluid can worsen the capillary leak syndrome and make maintaining
the circulating fluid volume even more difficult.

12. The client with a dressing covering the neck is experiencing some
respiratory difficulty. What is the nurse’s best first action?

A. Administer oxygen.
B. Loosen the dressing.
C. Notify the emergency team.
D. Document the observation as the only action.

12. Answer: B

Respiratory difficulty can arise from external pressure. The first action in this
situation would be to loosen the dressing and then reassess the client’s
respiratory status.
13. The client who experienced an inhalation injury 6 hours ago has
been wheezing. When the client is assessed, wheezes are no longer
heard. What is the nurse’s best action?

A. Raise the head of the bed.


B. Notify the emergency team.
C. Loosen the dressings on the chest.
D. Document the findings as the only action.

13. Answer: B

Clients with severe inhalation injuries may sustain such progressive obstruction
that they may lose effective movement of air. When this occurs, wheezing is no
longer heard and neither are breath sounds. The client requires the
establishment of an emergency airway and the swelling usually precludes
intubation.

14. Ten hours after the client with 50% burns is admitted,
her blood glucoselevel is 90 mg/dL. What is the nurse’s best action?

A. Notify the emergency team.


B. Document the finding as the only action.
C. Ask the client if anyone in her family has diabetes mellitus.
D. Slow the intravenous infusion of dextrose 5% in Ringer’s lactate.

14. Answer: B

Neural and hormonal compensation to the stress of the burn injury in the
emergent phase increases liver glucose production and release. An acute rise in
the blood glucose level is an expected client response and is helpful in the
generation of energy needed for the increased metabolism that accompanies
this trauma.
15. On admission to the emergency department the burned
client’s bloodpressure is 90/60, with an apical pulse rate of 122. These
findings are an expected result of what thermal injury–related
response?

A. Fluid shift
B. Intense pain
C. Hemorrhage
D. Carbon monoxide poisoning

15. Answer: A

Intense pain and carbon monoxide poisoning increase blood pressure.


Hemorrhage is unusual in a burn injury. The physiologic effect of histamine
release in injured tissues is a loss of vascular volume to the interstitial space,
with a resulting decrease in blood pressure.

18. What is the priority nursing diagnosis during the first 24 hours for a
client with full-thickness chemical burns on the anterior neck, chest,
and all surfaces of the left arm?

A. Risk for Ineffective Breathing Pattern


B. Decreased Tissue Perfusion
C. Risk for Disuse Syndrome
D. Disturbed Body Image

18. Answer: C

During the emergent phase, fluid shifts into interstitial tissue in burned areas.
When the burn is circumferential on an extremity, the swelling can compress
blood vessels to such an extent that circulation is impaired distal to the injury,
necessitating the intervention of an escharotomy. Chemical burns do not cause
inhalation injury.
20. The client has experienced an electrical injury, with the entrance
site on the left hand and the exit site on the left foot. What are the
priority assessment data to obtain from this client on admission?

A. Airway patency
B. Heart rate and rhythm
C. Orientation to time, place, and person
D. Current range of motion in all extremities

20. Answer: B

The airway is not at any particular risk with this injury. Electric current travels
through the body from the entrance site to the exit site and can seriously
damage all tissues between the two sites. Early cardiac damage from electrical
injury includes irregular heart rate, rhythm, and ECG changes.

21. In assessing the client’s potential for an inhalation injury as a result


of a flame burn, what is the most important question to ask the client
on admission?

A. “Are you a smoker?”


B. “When was your last chest x-ray?”
C. “Have you ever had asthma or any other lung problem?”
D. “In what exact place or space were you when you were burned?”

21. Answer: D

The risk for inhalation injury is greatest when flame burns occur indoors in
small, poorly ventilated rooms. although smoking increases the risk for some
problems, it does not predispose the client for an inhalation injury.

22. Which information obtained by assessment ensures that the client’s


respiratory efforts are currently adequate?
A. The client is able to talk.
B. The client is alert and oriented.
C. The client’s oxygen saturation is 97%.
D. The client’s chest movements are uninhibited

22. Answer: C

Clients may have ineffective respiratory efforts and gas exchange even though
they are able to talk, have good respiratory movement, and are alert. The best
indicator for respiratory effectiveness is the maintenance of oxygen saturation
within the normal range.

27. Which intervention is most important for the nurse to use to


prevent infection by cross-contamination in the client who has open
burn wounds?

A. Handwashing on entering the client’s room


B. Encouraging the client to cough and deep breathe
C. Administering the prescribed tetanus toxoid vaccine
D. Changing gloves between cleansing different burn areas

27. Answer: A

Cross-contamination occurs when microorganisms from another person or the


environment are transferred to the client. Although all the interventions listed
above can help reduce the risk for infection, only hand washing can prevent
cross contamination.

32. The client, who is 2 weeks postburn with a 40% deep partial-
thickness injury, still has open wounds. On taking the morning vital
signs, the client is found to have a below-normal temperature, is
hypotensive, and has diarrhea. What is the nurse’s best action?
A. Nothing, because the findings are normal for clients during the acute phase
of recovery.
B. Increase the temperature in the room and increase the IV infusion rate.
C. Assess the client’s airway and oxygen saturation.
D. Notify the burn emergency team.

32. Answer: D

These findings are associated with systemic gram-negative infection and sepsis.
This is a medical emergency and requires prompt attention.

3. Twelve hours after the client was initially burned, bowel sounds are
absent in all four abdominal quadrants. Which is the nurse’s best
action?

A. Administers a laxative
B. Documents the finding
C. Increases the IV flow rate
D. Repositions the client onto the right side

3. Answer: B. Documents the finding

Decreased or absent peristalsis is an expected response during the emergent


phase of burn injury as a result of neural and hormonal compensation to
the stress of injury. No currently accepted intervention changes this response.
It is not the highest priority of care at this time.

4. What intervention will the nurse implement to reduce a


client’s pain after a burn injury?

A. Administering morphine 4 mg intravenously.


B. Administering hydromorphone (Dilaudid) 4 mg intramuscularly.
C. Applying ice to the burned area
D. Avoiding tactile stimulation

4. Answer: A. Administering morphine 4 mg intravenously.

Drug therapy for pain management requires opioid and nonopioid analgesics.
The IV route is used because of problems with
absorption from the muscle and stomach. Tactile stimulation can be used
for painmanagement. For the client to avoid shivering, the room must be kept
warm and heat should be applied.

6. When providing care for a client with an acute burn injury, which
nursing intervention is most important to prevent infection by
autocontamination?

A. Avoiding sharing equipment such as blood pressure cuffs between clients


B. Changing gloves between wound care on different parts of the client’s body
C. Using the closed method of burn wound management
D. Using proper and consistent handwashing

6. Answer: B. Changing gloves between wound care on different parts


of the client’s body.

Autocontamination is the transfer of microorganisms from one area to another


area of the same client’s body, causing infection of a previously uninfected area.
Although all techniques listed can help reduce the risk for infection, only
changing gloves between carrying out wound care on different parts of the
client’s body can prevent autocontamination.
8. Which finding indicates that fluid resuscitation has been successful
for a client with a burn injury?

A. Hematocrit = 60%
B. Heart rate = 130 beats/min
C. Increased peripheral edema
D. Urine output = 50 mL/hr

8. Answer: D. Urine output = 50 mL/hr

The fluid remobilization phase improves renal blood flow, increases diuresis, and
restores blood pressure and heart rate to more normal levels, as well as
laboratory values.

9. Which finding indicates to the nurse that a client with a burn


injury has a positive perception of his appearance?

A. Allowing family members to change his dressings


B. Discussing future surgical reconstruction
C. Performing his own morning care
D. Wearing the pressure dressings as ordered

9. Answer: C. Performing his own morning care

Indicators that the client with a burn injury has a positive perception of his
appearance includes the willingness to touch the affected body part. Self-care
activities such as morning care foster feelings of self-worth, which are closely
linked to body image. Allowing others to change the dressing and discussing
future reconstruction would not indicate a positive perception of appearance.
Wearing the dressing will assist in decreasing complications, but will not
increase self-perception.
10. Which finding indicates to the nurse that the client understands the
psychosocial impact of his severe burn injury?

A. “It is normal to feel depressed.”


B. “I will be able to go back to work immediately.”
C. “I will not feel anger about my situation.”
D. “Once I get home, things will be normal.”

10. Answer: A. “It is normal to feel depressed.”

During the recovery period, and for some time after discharge from the
hospital, clients with severe burn injuries are likely to have psychological
problems that require intervention. Depression is one of these problems.
Feelings of grief, loss, anxiety, anger, fear, and guilt are all normal feelings that
can occur. Clients need to know that problems of physical care and
psychological stresses may be overwhelming.

11. Which finding is characteristic during the emergent period after a


deep full thickness burn injury?

A. Blood pressure of 170/100 mm Hg


B. Foul-smelling discharge from wound
C. Pain at site of injury
D. Urine output of 10 mL/hr

11. Answer: D. Urine output of 10 mL/hr

During the fluid shift of the emergent period, blood flow to the kidney may not
be adequate for glomerular filtration. As a result, urine output is greatly
decreaseD. Foul-smelling discharge does not occur during the emergent phase
and blood pressure is usually low. Pain does not occur with deep full-
thickness burns.

12. Which is the priority nursing diagnosis during the first 24 hours for
a client with chemical burns to the legs and arms that are red in color,
edematous, and without pain?

A. Decreased Tissue Perfusion


B. Disturbed Body Image
C. Risk for Disuse Syndrome
D. Risk for Ineffective Breathing Pattern

12. Answer: A. Decreased Tissue Perfusion

During the emergent phase, fluid shifts into interstitial tissue in burned areas.
When the burn is circumferential on an extremity, the swelling can compress
blood vessels to such an extent that circulation is impaired distal to the injury,
causing decreased tissue perfusion and necessitating the intervention of an
escharotomy. Chemical burnsdo not cause inhalation injury and a
disrupted breathing pattern. Disturbed body image and disuse syndrome can
develop. However, these are not priority diagnoses at this time.

13. Which laboratory result, obtained on a client 24 hours post-burn


injury, will the nurse report to the physician immediately?

A. Arterial pH, 7.32


B. Hematocrit, 52%
C. Serum potassium,7.5 mmol/L (mEq/L)
D. Serum sodium, 131 mmol/L (mEq/L)

13. Answer: C. Serum potassium,7.5 mmol/L (mEq/L)

The serum potassium level is changed to the degree that serious life-
threatening responses could result. With such a rapid rise in
the potassium level, the client is at high risk for experiencing severe cardiac
dysrhythmias and death. All the other findings are abnormal, but not to the
same degree of severity, and would be expected in the emergent phase after
a burn injury.

14. Which nursing intervention is likely to be most helpful in providing


adequate nutrition while the client is recovering from a thermal burn
injury?

A. Allowing the client to eat whenever he or she wants


B. Beginning parenteral nutrition high in calories
C. Limiting calories to 3000 kcal/day
D. Providing a low-protein, high-fat diet

14. Answer: A. Allowing the client to eat whenever he or she wants.

Clients should request food whenever they think that they can eat, not just
according to the hospital’s standard meal schedule. The nurse needs to work
with a nutritionist to provide a high-calorie, high-protein diet to help with wound
healing. Clients who can eat solid foods should ingest as many calories as
possible. Parenteral nutrition may be given as a last resort because it is invasive
and can lead to infectious and metabolic complications.