Stages
The client has a large burned area on the right arm. The burned area appears pink, has blisters, and is very painful. How will the nurse categorize this injury?
A. Full-thickness
B. Partial-thickness superficial
C. Partial-thickness deep
D. Superficial
Answer: B. Partial-thickness superficial
The characteristics of the wound meet the criteria for a superficial partial-thickness injury: color that is pink or red; blisters and pain present. Blisters are not seen with full-thickness and superficial burns, and are rarely seen with deep partial-thickness burns. Deep partial-thickness burns are red to white in color
A patient experienced a full-thickness burn 72 hours ago. The patient’s vital signs are within normal limits and urinary output is 50 mL/hr. This is known as what phase of burn management?
A. Emergent
B. Acute
C. Rehabilitative
The answer is B. This phase starts when capillary permeability has returned to normal and the patient’s vitals are within normal limits and ends with wound closure. The phase after this is rehabilitative.
A patient who is being treated for partial thickness burns on 60% of the body is now in the acute phase of burn management. The nurse assesses the patient for a possible Curling’s Ulcer. What signs and symptoms can present with this condition?
A. Swelling and pain on the area distal to the burn
B. Burning, gnawing sensation pain in the stomach and vomiting
C. Dark red or gray sores on the soles of the feet
D. Difficulty swallowing and gagging
The answer is B. This is a type of ulcer that occurs in the stomach, duodenum, due to a high amount of stress on the body from a burn. The blood supply to the factors that help protect the stomach lining from gastric erosion decreases and this allows for ulcers to form.
You’re assisting the nursing assistant with repositioning a patient with full-thickness burns on the neck. Which action by the nursing assistant requires you to intervene?
A. The nursing assistant elevates the head of the bed above 30 degrees.
B. The nursing assistant places a pillow under the patient’s head.
C. The nursing assistant places rolled towels under the patient’s shoulders.
D. The nursing assistant covers the patient with sterile linens.
The answer is B. If a patient has severe burns to the neck (head as well) a pillow should NOT be used under the head because this can cause wound contractions. Instead rolled towels should be placed under the shoulders.
A 58 year old female patient has superficial partial-thickness burns to the anterior head and neck, front and back of the left arm, front of the right arm, posterior trunk, front and back of the right leg, and back of the left leg. Using the Rule of Nines, calculate the total body surface area percentage that is burned?
A. 63%
B. 81%
C. 72%
D. 54%
The answer is A. Anterior head and neck (4.5%), front and back of the left arm (9%), front of the right arm (4.5%), posterior trunk (18%), front and back of the right leg (18%), back of the left leg (9%) which equals 63%
You receive a patient who has experienced a burn on the right leg. You note the burn contains small blisters and is extremely pinkish red and shiny/moist. The patient reports severe pain. You document this burn as:
A. 1st Degree (superficial)
B. 2nd Degree (partial-thickness)
C. 3rd Degree (full-thickness)
D. 4th Degree (deep full-thickness
The answer is B. These are the classic characteristics of a 2nd degree (partial-thickness) burn.
What are some patient priorities during the emergent phase of burn management?
A. Fluid volume
B. Respiratory status
C. Psychosocial
D. Wound closure
E. Nutrition
The answer is A and B. This phase starts from the onset of the burn and ends with the restoration of capillary permeability. Wound closure, and nutrition would be during the acute phase, and would continue into the rehabilitative phase. Psychosocial would be in the rehab phase.
As the nurse providing care to a patient who experienced a full-thickness electrical burn you know to monitor the patient’s urine for:
A. Hemoglobin and myoglobin
B. Free iron and white blood cells
C. Protein and red blood cells
D. Potassium and Urea
The answer is A. Patients who’ve experienced a severe electrical burn or full-thickness burns are at risk for acute kidney injury. This is because the muscles can experience damage from the electrical current leading them to release myoglobin. In addition, the red blood cells will release hemoglobin. These substances will collect in the kidneys leading to acute tubular necrosis (hence leading to AKI). Therefore, the nurse should monitor the patient’s urine for these substances.
True or False: A patient who experiences an alkali chemical burn is easier to treat because the skin will neutralize the chemical rather than with an acidic chemical burn.
False: Alkali burns are harder to treat than acidic chemical burns because the skin will neutralize the acidic burn.
A 30 year old female patient has deep partial thickness burns on the front and back of the right and left leg, front of right arm, and anterior trunk. The patient weighs 63 kg. Use the Parkland Burn Formula: What is the flow rate during the FIRST 8 hours (mL/hr) based on the total you calculated?
A. 921 mL/hr
B. 938 mL/hr
C. 158 mL/hr
D. 789 mL/hr
The answer is A: 921 mL/hr….First calculate the total amount of fluid needed with the formula: Total Amount of LR = 4 mL x BSA % x pt’s weight in kg. The pt’s weight 63 kg. BSA percentage: 58.5%…Front and back of right and left leg (36%), front of right arm (4.5%), anterior trunk (18%) which equals 58.5%. ……4 x 58.5 x 63 = 14,742 mL……Remember during the FIRST 8 hours 1/2 of the solution is infused, which will be 14,742 divided by 2 = 7371 mL……Hourly Rate: 7371 divide by 8 equals 921 mL/hr
The client has burns on both legs. These areas appear white and leather-like. No blisters or bleeding are present, and there is just a “small amount of pain.” How will the nurse categorize this injury?
A. Full-thickness
B. Partial-thickness superficial
C. Partial-thickness deep
D. Superficial
Answer: A. Full-thickness
The characteristics of the wounds 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. Partial-thickness superficial burns appear pink to red in color, with pain. Partial-thickness burn color is deep red to white in color with pain, and superficial burn color is pink to red, with pain.
During the emergent phase of burn management, you would expect the following lab values:
A. Low sodium, low potassium, high glucose, low hematocrit
B. High sodium, low potassium, low glucose, high hematocrit
C. High sodium, high potassium, high glucose, low hematocrit
D. Low sodium, high potassium, high glucose, high hematocrit
The answer is D. Think about the increase in the capillary permeability that happens with severe burns, which causes the plasma to leave the intravascular system and enter the interstitial tissue: Low sodium..why: sodium leaves with the plasma to the interstitial tissue and drops the levels in the blood; High potassium…why? damaged cells lysis and leak potassium which increases the leave in the blood; high glucose…why? stress response leads the liver to release glycogen and this increases levels; high hematocrit…why? when the plasma leaves the intravascular system (the fluid) it causes the blood to become more concentrated so hematocrit increases (this will decrease when the patient’s fluid is replaced).
A 65 year old male patient has experienced full-thickness electrical burns on the legs and arms. As the nurse you know this patient is at risk for the following: Select all that apply:*
The answers are A, B, C, and E. Electric burns are due to an electrical current passing through the body that leads to damage to the skin but also the muscles and bones that are underneath the skin. The patient is at risk for AKI (acute kidney injury) because when the muscles become affected they release myoglobin and the red blood cells release hemoglobin in the blood, which can collect in the kidneys leading to injury. In addition, the heart’s electrical system can become damaged leading to dysrhythmia. The iceberg effect can present as well because the extent of damage is not clearly visible on the skin (there can be severe damage underneath). In addition, if the electrical current is strong enough it can lead to bone fractures (specifically cervical spine injuries) due to the severe contraction of the muscles involved
The nurse notes a patient has full-thickness circumferential burns on the right leg. The nurse would: select all that apply
A. Place cold compressions on the burn and elevate the right leg below the heart level
B. Assess the distal pulses in the right extremity
C. Elevate the right leg above the heart level
D. Place gauze securely around the leg to prevent infection
The answer is B and C. The patient has burns that completely surround the front and back of the right leg. This can lead to compartment syndrome where the edema from the burn compromises circulation to the distal extremity. The nurse should elevate the extremity ABOVE heart level to decrease swelling and assess distal pulses in the extremity to confirm circulation is present
A 45 year old female patient has superficial partial thickness burns on the posterior head and neck, front of the left arm, front and back of the right arm, posterior trunk, front and back of the left leg, and back of right leg. The patient weighs 91 kg. Use the Parkland Burn Formula to calculate the total amount of Lactated Ringers that will be given over the next 24 hours?*
The answer is A: 22,932 mL
Formula: Total Amount of LR = 4 mL x BSA % x pt’s weight in kg
Pt’s weight 91 kg.
BSA percentage: 63%… posterior head and neck (4.5%), front of the left arm (4.5%), front and back of the right arm (9%), posterior trunk (18%), front and back of the left leg (18%), back of right leg (9%) equals: 63%
The client has experienced an electrical injury of the lower extremities. Which are the priority assessment data to obtain from this client?
A. Current range of motion in all extremities
B. Heart rate and rhythm
C. Respiratory rate and pulse oximetry reading
D. Orientation to time, place, and person
Answer: B. Heart rate and rhythm.
The airway is not at any particular risk with this injury. Therefore, respiratory rate and pulse oximetry are not priority assessments. 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. Range of motion and neurologic assessments are important. However, the priority is to make sure that the heart rate and rhythm are adequate to support perfusion to the brain and other vital organs.
During the acute phase of burn management, what is the best diet for a patient who has experienced severe burns?
A. High fiber, low calories, and low protein
B. High calorie, high protein and carbohydrate
C. High potassium, high carbohydrate, and low protein
D. Low sodium, high protein, and restrict fluids to 1 liter per day
The answer is B. This type of diet promotes wound healing and meets the caloric demands of the body.
Select the patient below who is at MOST risk for complications following a burn:
A. A 42 year old male with partial-thickness burns on the front of the right and left arms and legs.
B. A 25 year old female with partial-thickness burns on the front of the head and neck and front and back of the torso.
C. A 36 year old male with full-thickness burns on the front of the left arm.
D. A 10 year old with superficial burns on the right leg.
The answer is B. When thinking about which patient will have the MOST complications following a burn think about: percentage of the total body surface area that is burned (use the rule of nine to calculate), depth of the burn, age, location of the burn, and patient’s medical history. The patient in option B has 40.5% TSBA burned (option A 27%, C: 4.5%, D: 9%). Remember that the higher the total of the body surface area that is burned the higher the risk of complications due to an increase in capillary permeability (swelling, hypovolemic shock etc.). In addition, the location of the burn is a major issue with the patient in option B. The burns are on the head and neck and front and back of the torso. Therefore, with head and neck burns always think about respiratory issues because the airway can become compromised due to swelling or an inhalation injury. And with torso burns that are on the front and back, the patient is at risk for circumferential burns that can lead to further respiratory compromise. The other options have burns that are isolated.
A patient arrives to the ER with full-thickness burns on the front and back of the torso and neck. The patient has no spinal injuries but is disoriented and coughing up black sooty sputum. Vital signs are: oxygen saturation 63%, heart rate 145, blood pressure 80/56, and respiratory rate 39. As the nurse you will:
A. Place the patient in High Fowler’s positon.
B. Prep the patient for escharotomy.
C. Prep the patient for fasciotomy.
D. Prep the patient for intubation.
E. Place a pillow under the patient’s neck.
F. Obtain IV access at two sites.
G. Restrict fluids.
The answers are A, B, D, and F. After reading this scenario the location of the burns and the patient’s presentation should be jumping out at you. The patient is at risk for circumferential burns due to the location of the burns and the depth (full-thickness….will have eschar present that will restrict circulation or here in this example the ability of the patient to breathe in and out). Based on the patient’s VS, we see that the respiratory effort is compromised majorly AND that there is a risk of inhalation injury since the patient is coughing up black sooty sputum. Therefore, the nurse should place the patient in high Fowler’s position to help with respiratory effort (unless contraindicated with spinal injuries), prep the patient for escharotomy (this will cut the eschar and help relieve pressure and allow for breathing) and prep for intubation to help with the respiratory distress. In addition, obtain IV access in at least two sites for fluid replacement….remember the first 24 hours after a burn a patient is at risk for hypovolemic shock.
A 59 year old male patient has full thickness burns on both of the legs on the back, front and back of the trunk, both arms on the front and back, and front and back of the head and neck. The patient weighs 186 lbs. Use the Parkland Burn Formula: You’ve already infused fluids during the first 8 hours. Now what will you set the flow rate during the next 16 hours (mL/hr) based on the total you calculated?
A. 563 mL/hr
B. 854 mL/hr
C. 289 mL/hr
D. 861 mL/hr
The answer is D: 861 mL/hr First calculate the total amount of fluid needed with the formula: Total Amount of LR = 4 mL x BSA % x pt’s weight in kg. The pt’s weight 186 lbs…need to convert to kg: 186 divided by 2.2 = 85 kg
BSA percentage: 81%…Both of the legs on the back (18%), front and back of the trunk (36%), both arms on the front and back (18%), front and back of the head and neck (9%) which equals 81%.
At what point after a burn injury should the nurse be most alert for the complication of hypokalemia?
A Immediately following the injury
B During the fluid shift
C During fluid remobilization
D During the late acute phase
Option C: Hypokalemia is most likely to occur during the fluid remobilization period as a result of dilution, potassium movement back into the cells, and increased potassium excreted into the urine with the greatly increased urine output.
The burned client is ordered to receive intravenous cimetidine, an H2 histamine blocking agent, during the emergent phase. When the client’s family asks why this drug is being given, what is the nurse’s best response?
A. “To increase the urine output and prevent kidney damage.”
B. “To stimulate intestinal movement and prevent abdominal bloating.”
C. “To decrease hydrochloric acid production in the stomach and prevent ulcers.”
D. “To inhibit loss of fluid from the circulatory system and prevent hypovolemic shock.”
Option C: Ulcerative gastrointestinal disease may develop within 24 hours after a severe burn as a result of increased hydrochloric acid production and decreased mucosal barrier. Cimetidine inhibits the production and release of hydrochloric acid.
You are about to provide care to a patient with severe burns. You will don:
A. gloves
B. goggles
C. gown
D. N-95 mask
E. surgical mask
F. shoe covers
G. hair cover
The answer is A, C, E, F, and G. Before providing care to a patient with severe burns the nurse would want to wear protective isolation apparel like: gloves, gown, surgical mask, shoe covers, and hair cover. This protects the patient from potential infection.
While collecting a medical history on a patient who experienced a severe burn, which statement by the patient’s family member requires nursing intervention?
A. “He takes medication for glaucoma”.
B. “I think it has been 10 years or more since he had a tetanus shot.”
C. “He was told he had COPD last year.”
D. “He smokes 2 packs of cigarettes a day.”
The answer is B. Patients who have had burns need a tetanus shot if they have not had a vaccine within the past 5 to 10 years.
A 29 year old male patient has superficial thickness burns on the anterior right arm, posterior left leg, and anterior head and neck. The patient weighs 78 kg. Use the Parkland Burn Formula to calculate the total amount of Lactated Ringers that will be given over the next 24 hours?*
none! no IV fluid replacement for first degree burns