Disco Inferno
The nurse monitors for which assessment findings in the patient admitted with superficial partial-thickness burns over both anterior lower arms?
A. Dry with no blisters
B. Waxy appearance and cherry red color
C. Dry, leathery appearance and pale or brown color
D. Open or closed blisters, mild edema, and easily blanches
D. Open or closed blisters, mild edema, and easily blanches
A superficial partial-thickness burn has blisters that may be closed or open and weeping, pink or red, with mild edema, and blanch easily.
The nurse monitors for which assessment findings in the patient treated outpatient with superficial burns over both anterior lower arms?
A. Dry with no blisters
B. Waxy appearance and cherry red color
C. Dry, leathery appearance and pale or brown color
D. Open or closed blisters, mild edema, and easily blanches
A. Dry with no blisters
A superficial burn is dry with blisters.
The nurse monitors for which assessment findings in the patient admitted with full-thickness burns over both anterior lower arms?
A. Dry with no blisters
B. Waxy appearance and cherry red color
C. Dry, leathery appearance and pale or brown color
D. Open or closed blisters, mild edema, and easily blanches
C. Dry, leathery appearance and pale or brown color
Full-thickness burns are dry, leathery, and pale, white, brown, or black in color.
The nurse monitors for which assessment findings in the patient admitted with deep partial-thickness burns over both anterior lower arms?
A. Dry with no blisters
B. Waxy appearance and cherry red color
C. Dry, leathery appearance and pale or brown color
D. Open or closed blisters, mild edema, and easily blanches
B. Waxy appearance and cherry red color
Deep-partial thickness burns have a waxy appearance and are cherry red.
A victim of a house fire is brought to the emergency department for burn treatment. The nurse correlates which assessment to an inhalation injury?
A. Coughing
B. Soot on the face
C. Singed facial hair
D. Heart rate 98 bpm
C. Singed facial hair
Patients with an inhalation injury may present with singed facial hair.
Coughing does not indicate an inhalation injury.
Soot in the sputum, not on the face, may indicate an inhalation injury.
An elevated heart rate is expected in this situation, but an elevated pulse may be caused by other factors and is not definitive for an inhalation injury.
In caring for a patient with 50% total body surface area burns, the nurse correlates which finding to resolution of burn shock?
A. Heart rate 112 bpm
B. Respirations 24 per minute
C. Blood pressure 90/60 mm Hg
D. Urine output 800 mL over 2 hours
D. Urine output 800 mL over 2 hours
In the postburn shock phase, which begins 24 to 48 hours after injury, the capillaries begin to regain integrity. Burn shock slowly begins to resolve, and the fluid gradually returns to the intravascular space. Urinary output continues to increase secondary to patient diuresis.
The nurse is caring for a patient with 45% total body surface area thermal burns. The nurse monitors for which laboratory result?
A. Increased pH
B. Increased sodium
C. Increased potassium
D. Decreased hematocrit
C. Increased potassium
Hyperkalemia is expected because of massive cellular trauma causing the release of potassium into extracellular fluid.
Acidosis or a decreased pH can occur because of a loss of bicarbonate ions.
Decreased sodium is expected because large amounts of sodium are lost to third spacing, wound draining, and shifting into cells as potassium is released.
An elevated hematocrit is expected because plasma is lost to extravascular spaces, leaving the remaining blood very viscous.
In providing care to a patient admitted with a suspected inhalation injury, what nursing action is the priority?
A. Administering intravenous lactated Ringer’s fluid
B. Turning in bed every 2 hours
C. Monitoring intake and output
D. Administering 100% humidified oxygen
D. Administering 100% humidified oxygen
Ensuring a patent airway and administering 100% oxygen is the priority in the patient with an inhalation injury. Deep breathing and coughing should be done every hour to assist with airway clearance and mobilization of secretions.
Fluid resuscitation is important if there are other burn injuries, but airway and oxygenation are the priorities with inhalation injuries.
Turning in bed every 2 hours is essential to reduce the hazards of immobility and promote gas exchange; however, it is not as important as administering oxygen.
Monitoring intake and output is important for a patient with burns, but administering oxygen is the priority.
The nurse is delivering fluids to a patient with a 30% total body surface area burn injury during the emergent phase. Which finding should be reported to the healthcare provider?
A. An increase in the heart rate to 110 bpm
B. Pain of 9 out of 10 after IV opioid pain medications
C. Urine output 25 mL/hr
D. Patient screaming and crying uncontrollably
C. Urine output 25 mL/hr
During the emergent phase while administering fluid resuscitation to a patient with a large burn injury, the nurse should notify the healthcare provider immediately if the hourly urine output is below 30 mL since decreased perfusion is present.
Tachycardia is expected because of fluid shifts, anxiety, and pain.
Pain will be extreme and multiple doses of opioids will be needed for relief.
Stress and pain reactions are anticipated.
A patient is ending the first year of recovery after having burns to both legs. Which observation indicates that the patient needs to be encouraged to wear the pressure garment?
A. Skin warm and moist
B. Pedal pulses present but faint
C. Scattered areas of scarring noted
D. Nonpitting edema of both ankles
C. Scattered areas of scarring noted
Specialty pressure garments are intended to provide continuous and uniform pressure over the area of burn to prevent hypertrophic scarring. These garments are to be worn 23 hours a day for up to a year or more after injury in some patients. The presence of scarring indicates the garment has not been worn consistently.
Warm and moist skin would not indicate that the pressure garment is not being worn.
Faint pedal pulses would indicate sluggish perfusion.
Nonpitting edema of both ankles would not be associated with the pressure garment.
The nurse is caring for a patient who sustained electrical burns. What is the rationale for monitoring this patient for compartment syndrome?
A. Potential for undiagnosed injuries
B. Injuries from being thrown cause bruising of soft tissue
C. Electrical current alters integrity of blood vessels
D. Fluid seeps from intravascular spaces into the interstitium
D. Fluid seeps from intravascular spaces into the interstitium
Pulses are closely monitored in all affected extremities for the first 48 hours postinjury to assess for the potential development of compartment syndrome. As fluid seeps from the intravascular spaces into the interstitium, pressure within the tissues continues to rise and confines swelling inside muscle compartments.
The nurse provides care to a patient who is in the emergency department (ED) with a burn injury. What is the priority action by the nurse during the emergent phase of care?
A. Providing pain medications
B. Placing an indwelling urinary catheter
C. Administering the prescribed high-flow 100% oxygen by mask
D. Inserting two large-bore intravenous catheters in preparation for fluid resuscitation
C. Administering the prescribed high-flow 100% oxygen by mask
This is the priority action. Nurses use the ABCs to prioritize care. Once the patient’s airway is stabilized, the next priority is breathing, which is addressed by administering high-flow 100% oxygen by mask.
All other interventions are appropriate, however, not the priority action for this patient.
In providing care to a patient with 70% total body surface area chemical burns, the nurse correlates which as most effective in meeting this patient’s nutritional needs?
A. Parenteral nutrition
B. Duodenal tube feedings
C. Nasogastric tube feedings
D. Six small high-calorie meals per day
B. Duodenal tube feedings
In large burn injuries, longer nutritional support is required, and placement of a duodenal feeding tube is often recommended to help prevent aspiration and allow for feeding up to and during procedures.
Total parenteral nutrition is not often used among burn patients because of its complication rates, including an increased risk for infection and hyperglycemia.
Nutritional supplementation is most often achieved through the placement of a nasogastric tube, where feedings can be given continuously or intermittently in the form of a bolus. However, the patient has a large total body surface area burned. Another approach would be more appropriate.
Once a person has sustained a burn of approximately 20% or greater, it is difficult to consume the number of calories and protein needed for wound healing.
The nurse cares for a patient in the emergency department with a new burn from a liquid chemical spill at work. What action should the nurse take before performing care?
A. Inquire from emergency medical services the chemical that caused the burn.
B. Don appropriate personal protective equipment (PPE).
C. Flush the burn with sterile water.
D. Assess the patient’s vital signs.
B. Don appropriate personal protective equipment (PPE).
It is imperative that healthcare workers ensure that the scene is safe and protect themselves using the appropriate personal protective equipment (PPE) when a chemical injury is suspected.
It is nice to know the chemical, but the focus of care should be on protecting the healthcare team and treating the patient.
Flushing of the burn will likely take place after PPE has been applied.
Assessment of the vital signs will take place after the PPE has been applied.
A patient has full-thickness burns over 30% of total body surface area. Which intervention to address the patient’s comfort does the nurse question?
A. Elevate injured extremities.
B. Medicate for pain around the clock.
C. Apply medicated ointment to all areas.
D. Elevate the head of the bed 30 degrees.
B. Medicate for pain around the clock.
A full-thickness burn involves destruction of the epidermis, the dermis, and portions of the subcutaneous tissue. All epidermal and dermal structures are destroyed, including hair follicles, sweat glands, and nerve endings. As a result of the extensive damage to the nerve endings, full-thickness burns are insensate to palpation and often are not painful. Pain medication would be least likely to provide comfort to this patient initially.
A patient has been recovering for 18 months from burns that affected 60% total body surface area. For which complications does the nurse provide care to this patient? Select all that apply.
A. Hyperkalemia
B. Depression
C. Fluid volume deficit
D. Body image disorder
E. Post-traumatic stress disorder (PTSD)
B. Depression
D. Body image disorder
E. Post-traumatic stress disorder (PTSD)
The burn patient may endure many psychological and emotional challenges throughout the lengthy course of treatment and recovery. The patient may experience depression, body image disorder, and/or post-traumatic stress disorder (PTSD).
The nurse cares for a patient with a new superficial, partial-thickness burn of the face and neck. The patient is crying and asking if it will heal. Which statements can the nurse share about this type of burn? Select all that apply.
A. The burn is in the top layer of the skin and a little in the deep tissues.
B. Blisters may develop and sometimes leave scars.
C. It will be very painful until it heals.
D. Healing may take 1–2 weeks.
E. Scarring will be minimal.
A. The burn is in the top layer of the skin and a little in the deep tissues.
C. It will be very painful until it heals.
D. Healing may take 1–2 weeks.
This is correct. The entire epidermis is burned with a superficial, partial-thickness burn. There is minimal damage to the dermis. This type of burn is very painful. Healing is typically 7–14 days.
B & E are incorrect. Blisters are likely to develop, but scarring is not a problem. No scarring will occur with this type of burn.
6. The nurse cares for a patient with a large burn during the emergent phase. Which lab results are anticipated?
A. High serum osmolality
B. Low potassium level
C. Low sodium level
D. High urine osmolality
E. High hematocrit
A. High serum osmolality
This is correct. Plasma leaks through damaged capillaries (third spacing) and into interstitial spaces, causing the vascular space to be dry with a high osmolality.
C. Low sodium level
This is correct. Large amounts of sodium are lost to third spacing, wound drainage, and shifting into cells as potassium is released.
D. High urine osmolality
This is correct. Urine output decreases and the urine becomes more concentrated.
E. High hematocrit
This is correct. Plasma is lost to extravascular spaces, leaving the remaining blood very viscous and elevating the hematocrit.
B is incorrect. Massive cellular trauma causes the release of potassium into extracellular fluid, leading to hyperkalemia.
The nurse recognizes that burns to which body areas meet the criteria for referral to a burn center because of the increased risk of functional changes? (Select all that apply.)
A. Chest
B. Perineum
C. Abdomen
D. Face
E. Hands
F. Genitalia
G. Feet
B. Perineum
D. Face
E. Hands
F. Genitalia
G. Feet
According to the American Burn Association, referral criteria to a burn center involves injuries to specific areas of the body including the face, hands, feet, genitalia, perineum, and burns over major joints. Burns in these locations involve functional areas of the body and may require specialized and highly skilled intervention in order to restore optimal function
The nurse correlates which clinical manifestations to the possibility of an inhalation injury? (Select all that apply.)
A. Facial burns
B. Singed nasal hairs
C. Soot in the sputum
D. Hoarseness
E. Eschar
A. Facial burns
B. Singed nasal hairs
C. Soot in the sputum
D. Hoarseness
Patients that have sustained an inhalation injury may have facial burns, singed nasal hairs, soot in their sputum, and hoarseness caused by edema and irritation. An abnormal EKG is not indicative of an inhalation injury.
A patient weighing 80 kg sustains a burn at 1200 covering approximately 40% TBSA. The patient is a young healthy male with no medical history. Using the Parkland formula, how much fluid should be infused by 1600?
A. 12,800 ml lactated Ringer’s
B. 6,400 ml lactated Ringer’s
C. 3,200 ml lactated Ringer’s
D. 1,600 ml lactated Ringer’s
C. 3,200 ml lactated Ringer’s
The Parkland formula is 4 ml × 80 kg × 40% TBSA = 12,800 ml. Half of this amount (6,400 ml) needs to be given in the first 8 hours; therefore, half that amount (3,200 ml) needs to be given within the first 4 hours of resuscitation
A patient weighing 70 kg sustains a burn at 1500 covering approximately 60% TBSA. The patient is a young healthy female with no medical history. Using the Parkland formula, how much fluid should be infused by 1900?
A. 16,800 ml lactated Ringer’s
B. 8,400 ml lactated Ringer’s
C. 4,200 ml lactated Ringer’s
D. 2,100 ml lactated Ringer’s
C. 4,200 ml lactated Ringer’s
The Parkland formula is 4 ml × 70 kg × 60% TBSA = 16,800 ml. Half of this amount (8,400 ml) needs to be given in the first 8 hours; therefore, half that amount (4,200 ml) needs to be given within the first 4 hours of resuscitation
A patient weighing 90 kg sustains a burn at 1000 covering approximately 30% TBSA. The patient is a young healthy male with no medical history. Using the Parkland formula, how much fluid should be infused by 1800?
A. 10,800 ml lactated Ringer’s
B. 5,400 ml lactated Ringer’s
C. 2,700 ml lactated Ringer’s
D. 1,350 ml lactated Ringer’s
B. 5,400 ml lactated Ringer’s
The Parkland formula is 4 ml × 90 kg × 30% TBSA = 10,800 ml. Half of this amount (5,400 ml) needs to be given in the first 8 hours.
A patient weighing 60 kg sustains a burn at 1100 covering approximately 70% TBSA. The patient is a young healthy female with no medical history. Using the Parkland formula, how much fluid should be infused by 1500?
A. 16,800 ml lactated Ringer’s
B. 4,200 ml lactated Ringer's
C. 8,400 ml lactated Ringer’s
D. 2,100 ml lactated Ringer’s
B. 4,200 ml lactated Ringer's
The Parkland formula is 4 ml × 60 kg × 70% TBSA = 16,800 ml. Half of this amount (8,400 ml) needs to be given in the first 8 hours; therefore, half that amount (4,200 ml) needs to be given within the first 4 hours of resuscitation.
A patient weighing 176 lbs sustains a burn at 1200 covering approximately 40% TBSA. The patient is a young healthy male with no medical history. Using the Parkland formula, how much fluid should be infused by 2000?
A. 12,800 ml lactated Ringer’s
B. 6,400 ml lactated Ringer’s
C. 3,200 ml lactated Ringer’s
D. 1,600 ml lactated Ringer’s
B. 6,400 ml lactated Ringer’s