Burn A
Burn B
Trauma A
Trauma B
Miscellaneous
100
What does the rule of nines calculate?
The total body surface area of burn % (TBSA).
100
What are the 6 P's of compartment syndrome?
Pain, pallor, paresthesia, paralysis, pulselessness, and poikilothermia
100
What's included in the secondary survey when using the Trauma Nursing Process (TNP)?
Thorough head-to-toe assessment (including posterior), keep pt warm, continually reassess vitals/pain and SAMPLE history.
100
Your trauma patient has a GCS of 6? What do you anticipate an intervention that needs to be performed?
Intubation-usually for 8 or less
100
A pt that weighs 104 kg has partial to full thickness burns to her anterior abdomen, anterior bilateral legs, and right circumferential arm. Calculate the amount of fluid given to this patient using the 4ml/kg formula. Use the Rule of 9's to determine TBSA.
Calculate the amount of fluid to be given over the first 8 hours and the rate in ml/hr.
Anterior abdomen=18%, Ant. bilat. legs=18%, Circumferential R arm=9% this totals 45% TBSA
104kg x 4ml x 45= 18,720ml/kg fluid to be administered to this patient.
18,720/2= 9,360ml over 8 hours
9360/8=1,170ml/hr.
200
An electrical burn patient has an elevated myoglobin level. What does the nurse recall is the goal level of urinary output for this type of patient?
Goal is 1 mL/kg/hr for patients with electrical burns and myoglobin in the urine.
200
What are the 3 burn phases?
Emergent (resuscitative), intermediate (acute), rehabilitative
200
In cases of potential spinal cord injury, which airway-opening maneuver should be performed to maintain the stability of the cervical spine?
Jaw thrust maneuver
200
Which is worse, decorticate or decerebrate posturing? What does it indicate? What injury pattern is associated with this type of sign?
Decerebrate is more severe, it is a sign of ICP and damage to the brainstem/midbrain/pons, impending herniation.
This injury is typically associated with TBI.
200
The nurse notices this rhythm on the patient's cardiac monitor:
What does she identify this as? What is the HR?
Supraventricular Tachycardia, HR 200.
300
Which category of shock are you trying to prevent when treating burn patients?
Hypovolemic/distributive
300
The nurse is preparing a burn patient for wound debridement and a dressing change. What is most important to address prior to this procedure?
Administer medication to the patient in advance to manage pain.
300
When caring for a patient with a rattlesnake bite, what are some things that can be done to decrease the circulation of venom?
Immobilize the extremity and keep it below heart level. Rest to prevent circulation of venom; remove jewelry and clothing from the area due to impending edema. Administer antivenin as soon as possible.
300
What is the 1:1:1 method in massive trauma fluid resuscitation?
During fluid resuscitation, utilize the equalization of NS and LR crystalloids and begin infusion of equal parts of PRBC, FFP, and platelets.
300
A nurse notices this rhythm below on the cardiac monitor. What does the nurse identify this rhythm as and what does the nurse need to know about this patient to determine the treatment pathway?
Ventricular tachycardia: does the pt have a pulse or not? V-tach with a pulse or pulseless V-tach requires differing treatment algorithms.
400
Findings of soot in the upper airway, singed facial hair, or carbonaceous sputum indicate the presence of what type of burn?
Inhalation injury/burns
400
True or False: Rehabilitation should begin immediately after the burn has occurred.
True-could include ROM, maintaining fluid/electrolyte balance, improving nutritional status, psychosocial support, monitoring for complications (close assessment)
400
Which type of oxygen delivery device is indicated initially for a critically injured patient?
NRB placed on 100% oxygen
400
What are the symptoms of Beck's triad?
What does it indicate? What is the treatment for this emergent condition?
Hypotension, JVD, muffled heart tones
It occurs when fluid occurs in the pericardial sac, compressing the heart and inhibiting its ability to pump effectively (cardiac tamponade).
Treatment is the removal of fluid via pericardiocentesis.
400
A nurse observes a change in rhythm on the patient's telemetry. How does he identify this rhythm? What risks are associated with this rhythm, and which medication group should the patient receive?
Atrial fibrillation
Pt is at high risk for blood clots causing Stroke/PE
Anticoagulant medication
500
What is the Parkland formula used for?
Fluid resuscitation for burn patients
500
How does the nurse assist the burn patient in preventing contractures following skin grafting on the neck, head, and hands?
Promote extension of joints, splinting and ROM exercises, elastic bandages, and pressure garments. Avoid pillows to the neck area.
500
What is the Glascow Coma Scale used to assess? What is the minimum score? What is the maximum score?
Assesses 3 aspects of responsiveness: eye-opening, motor, and verbal response. The minimum score is 3; max is 15.
500
What are some signs/symptoms of hypoperfusion?
Skin pallor, delayed capillary refill, cool/clammy skin, hypotension, weak/thready pulses, tachypnea, hypotension, decreased UOP, altered LOC.
500
An 88 kg pt. has received deep-partial thickness burns to circumferential bilateral legs, posterior torso, and posterior head. Estimate the TBSA % using the rule of 9's.
Then, calculate the fluid for this patient using the 2ml/kg formula.
Calculate the amount to be given over the first 8 hours and the rate that it is given in ml/hr.
Calculate the amount given over the next 16 hours and the rate it is given in ml/hr.
Circumferential bilat. legs= 36%, post. abdomen=18%, post. head=4.5% total= 58.5 or 58.5% TBSA.
58.5 x 88kg x 2ml= 10,296ml/kg/TBSA
10,296/2=5,148 to be given in 1st 8 hours. 5,148/8=643.5 ml/hr rate.
5,148/16= 321.75 or 321.8ml/hr rate of infusion over the next 16 hours.