1. A 21-year-oldpatient who is inthe rehabilitationphase after havingdeep partial-thickness face andneck burns has anursing diagnosisof disturbed bodyimage. Whichaction by thepatient indicatesthat the problem isresolving?

Asking about how to use make-up tocover up the scars.

rationale:The willingness to use strategies toenhance appearance is an indicationthat the disturbed body image isresolving. Expressing feelings aboutthe scars indicates a willingness todiscuss appearance, but not resolutionof the problem. Because deep partial-thickness burns leave permanent scars,a statement that the scars aretemporary indicates denial rather thanresolution of the problem. Avoidingusing a pillow will help preventcontractures, but it does not address theproblem of disturbed body image.

2. A 70 kg patient withburns over 30% oftotal body surfacearea (TBSA) isadmitted to theburn unit. Usingthe Parklandformula, calculatethe volume oflactated Ringer'ssolution that thenursing staff willadminister duringthe first 24 hours._____________

8400 mL

rationale:The Parkland formula states thatpatients should receive 4mL/kg/%TBSA burned during the first24 hours.

3. A patient isadmitted to theburn unit withburns to the upperbody and headafter a garage fire.Initially, wheezesare heard, but anhour later, the lungsounds aredecreased and nowheezes areaudible. What isthe best action forthe nurse to take?

Notify the health care provider andprepare for endotracheal intubation.

rationale:The patient's history and clinicalmanifestations suggest airway edemaand the health care provider shouldimmediately be notified so thatintubation can rapidly be done. Placingthe patient in a more upright positionor having the patient cough will notaddress the problem of airway edema.Continuing to monitor is inappropriatebecause immediate action should occur.

4. A patient who hasburns on the backand chest from ahouse fire hasbecome agitatedand restless 9hours after beingadmitted to thehospital. Whichaction should thenurse take first?

Use pulse oximetry to check the oxygensaturation.

rationale:Agitation in a patient who may havesuffered inhalation injury might indicatehypoxemia, and this should be assessedby the nurse first. Administration ofmorphine may be indicated if the nursedetermines that the agitation is caused bypain. Assessing level of consciousnessand orientation also is appropriate butnot as essential as determining whetherthe patient is hypoxemic. Reassurance isnot helpful to reduce agitation in ahypoxemic patient.

5. A patient withcircumferentialburns of botharms develops adecrease inradial pulsestrength andnumbness in thefingers. Whichaction should thenurse take?

Notify the health care provider.

rationale:The decrease in pulse in a patient withcircumferential burns indicates decreasedcirculation to the arms and the need forescharotomy. Monitoring the pulses isnot an adequate response to the decreasein circulation. Elevating the hands orincreasing hand movement will notimprove the patient's circulation.

6. A patient withdeep partial-thickness andfull-thicknessburns of the faceand chest ishaving thewounds treatedwith the openmethod. Whichnursing actionwill be includedin the plan ofcare?

Wear gowns, caps, masks, and glovesduring all care of the patient.

rationale:Use of gowns, caps, masks, and glovesduring all patient care will decrease thepossibility of wound contamination for apatient whose burns are not covered.Restricting all visitors is not necessaryand will have adverse psychosocialconsequences for the patient. The roomtemperature should be kept atapproximately 85° F for patients withopen burn wounds. Systemic antibioticsare not well absorbed into deep burnsbecause of the lack of circulation.

7. A patient withextensiveelectrical burninjuries isadmitted to theemergencydepartment.Which of theseprescribedinterventionsshould the nurseimplement first?

Place on cardiac monitor.

rationale:After an electrical burn, the patient is atrisk for fatal dysrhythmias and should beplaced on a cardiac monitor. The otheractions should be accomplished in thefollowing order: Start two IVs, assess forpain, and apply dressings.

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8. A patient with severe burnshas crystalloid fluidreplacement ordered using theParkland formula. The initialvolume of fluid to beadministered in the first 24hours is 30,000 mL. Theinitial rate of administrationis 1875 mL/hr. After the first 8hours, the nurse will decreasethe fluid infusion rate to______________

938 mL/hour.

rationale:Half of the fluidreplacement using theParkland formula isadministered in the first 8hours and the other halfover the next 16 hours. Inthis case, the patientshould receive half of theinitial rate, or 938 mL/hr.

9. After an employee spillsindustrial acids on the armsand legs at work, what is thepriority action that theoccupational health nurse atthe facility should take?

Flush the burned areawith large amounts ofwater.

rationale:With chemical burns, theinitial action is to removethe chemical from contactwith the skin as quicklyas possible. Covering theaffected area or placingcool compresses on thearea will leave thechemical in contact withthe skin. Application ofan alkaline solution isnot recommended.

10. After receiving change-of-shiftreport, which of these patientsshould the nurse assess first?

A patient with smokeinhalation who haswheezes and alteredmental status

rationale:This patient has evidenceof lower airway injuryand hypoxemia andshould be assessedimmediately to determineneed for oxygen orintubation. The otherpatients also should beassessed as rapidly aspossible, but they do nothave evidence of life-threateningcomplications.

11. During the emergentphase of burn care, whichnursing action will bemost useful indetermining whether thepatient is receivingadequate fluid infusion?

Measure hourly urine output.

rationale:When fluid intake is adequate,the urine output will be at least0.5 to 1 mL/kg/hour. Thepatient's weight is not useful inthis situation because of theeffects of third spacing andevaporative fluid loss. Mucousmembrane assessment andskin turgor also may be used,but they are not as adequate indetermining that fluidinfusions are maintainingadequate perfusion.

12. In which order will thenurse take these actionswhen doing a dressingchange for a partial-thickness burn wound ona patient's back? Put acomma and spacebetween each answerchoice _____________

d) Administer IV fentanyl(Sublimaze).e) Clean wound with saline-soaked gauze.c) Apply silver sulfadiazinecream.a) Apply sterile gauze dressing.b) Document woundappearance.

rationale:Since partial-thickness burnsare very painful, the nurse'sfirst action should be toadminister pain medications.The wound will then becleaned, antibacterial creamapplied, and covered with anew sterile dressing. The lastaction should be to documentthe appearance of the wound.

13. On admission to the burnunit, a patient with anapproximate 25% totalbody surface area (TBSA)burn has the followinginitial laboratory results:Hct 56%, Hb 17.2 mg/dL(172 g/L), serum K+ 4.8mEq/L (4.8 mmol/L), andserum Na+ 135 mEq/L(135 mmol/L). Whichaction will the nurseanticipate taking?

Increase the rate of the orderedIV solution.

rationale:The patient's lab data showhemoconcentration, whichmay lead to a decrease in bloodflow to the microcirculationunless fluid intake isincreased. Documentation andcontinuing to monitor areinadequate responses to thedata. Since the hematocrit andhemoglobin are elevated, atransfusion is inappropriate,although transfusions may beneeded after the emergentphase.

14. Ranitidine (Zantac)is prescribed for apatient whoincurred extensiveburn injuries 5 daysago. Whichinformation will thenurse collect toevaluate theeffectiveness of themedication?

Stools for occult blood

rationale:H2 blockers are given to preventCurling's ulcer in the patient who hassuffered burn injuries. H2 blockers donot impact on bowel sounds, stoolfrequency, or appetite.

15. Six hours after athermal burncovering 50% of apatient's total bodysurface area(TBSA), the nurseobtains these datawhen assessing apatient. What is thepriorityinformation tocommunicate to thehealth careprovider?

Urine output is 20 mL per hour for thepast 2 hours.

rationale:The urine output should be at least0.5 to 1.0 mL/kg/hr during theemergent phase, when the patient isat great risk for hypovolemic shock.The nurse should notify the healthcare provider because a higher IVfluid rate is needed. BP during theemergent phase should be greaterthan 90 systolic, and the pulse rateshould be less than 120. Serousexudate from the burns is expectedduring the emergent phase.

16. The nurse caring fora patient admittedwith burns over 30%of the body surfacewill recognize thatthe patient hasmoved from theemergent to theacute phase of theburn injury when______________

the patient has large quantities ofpale urine.

rationale:At the end of the emergent phase,capillary permeability normalizes andthe patient begins to diurese largeamounts of urine with a low specificgravity. Although this may occur atabout 48 hours, it may be longer insome patients. Blisters and edemabegin to resolve, but this processrequires more time. White blood cellsmay increase or decrease, based onthe patient's immune status and anyinfectious processes.

17. The nurse is estimatingthe extent of a burnusing the rule of ninesfor a patient who hasbeen admitted withdeep partial-thicknessburns of the posteriortrunk and right arm.What percentage of thepatient's total bodysurface area (TBSA) hasbeen injured?__________________

27%

rationale:When using the rule of nines, theposterior trunk is considered tocover 18% of the patient's bodyand each arm is 9%.

18. The nurse notes a brightred skin color for apatient who was foundunconscious fromsmoke inhalation in aburning house. Whichaction should the nursetake first?

Place the patient on 100%oxygen using a non-rebreathermask.

rationale:The patient's history and skincolor suggest carbon monoxidepoisoning, which should betreated by rapidly starting oxygenat 100%. The other actions canbe taken after the actions tocorrect gas exchange.

19. The RN observes all ofthe following actionsbeing taken by a staffnurse who has floated tothe unit. Which actionrequires that the RNintervene?

The float nurse uses clean latexgloves when applyingantibacterial cream to a burnwound.

rationale:Sterile gloves should be wornwhen applying medications ordressings to a burn.Hypothermia is an indicator ofpossible sepsis, and cultures areappropriate. Nondiabeticpatients may require insulinbecause stress and high calorieintake may lead to temporaryhyperglycemia. Fentanyl peaks 5minutes after IV administrationand should be used just beforeand during dressing changes forpain management.

20. To maintainadequate nutritionfor a patient whohas just beenadmitted with a40% total bodysurface area(TBSA) burninjury, the nursewill plan to____________

insert a feeding tube and initiate enteralfeedings.

rationale:Enteral feedings can usually beinitiated during the emergent phase atlow rates and increased over 24 to 48hours to the goal rate. During theemergent phase, the patient will beunable to eat enough calories to meetnutritional needs and may have aparalytic ileus that prevents adequatenutrient absorption. Vitamins andminerals may be administered duringthe emergent phase, but these will notassist in meeting the patient's caloricneeds. Parenteral nutrition increasesthe infection risk, does not helppreserve gastrointestinal function, andis not routinely used in burn patients.

21. What is thepriority nursingassessment whencaring for apatient who hasjust arrived in theemergencydepartment aftersuffering anelectrical burnfrom exposure to ahigh-voltagecurrent?

Extremity movement

rationale:All patients with electrical burnsshould be considered at risk for cervicalspine injury, and assessments ofextremity movement will providebaseline data. The other assessmentdata also are necessary but not asessential as determining cervical spinestatus.

22. When assessing apatient whospilled hot oil onthe right leg andfoot, the nursenotes that the skinis red, swollen,and covered withlarge blisters. Thepatient states thatthey are verypainful. The nursewill document theinjury as______________

deep partial-thickness skin destruction.

rationale:The erythema, swelling, and blisterspoint to a deep partial-thickness burn.With full-thickness skin destruction,the appearance is pale and dry orleathery and the area is painlessbecause of the associated nervedestruction. With superficial partial-thickness burns, the area is red, but noblisters are present.

23. Which actionwill be includedin the plan ofcare for apatient whohas burns ofthe ears, head,neck, and rightarm and hand?

Elevate the right arm and hand on pillowsand extend the fingers.

rationale:The right hand and arm should be elevatedto reduce swelling and the fingers extendedto avoid flexion contractures (even thoughthis position may not be comfortable for thepatient). The patient with burns of the earsshould not use a pillow since this will putpressure on the ears and may stick to theears. Patients with neck burns should notuse a pillow, since the head should bemaintained in an extended position inorder to avoid contractures.

24. Which of theseactions shouldthe nurse takefirst when apatient arrivesin theemergencydepartmentwith facial andchest burnscaused by ahouse fire?

Auscultate the patient's lung sounds.

rationale:A patient with facial and chest burns is atrisk for inhalation injury, and assessmentof airway and breathing is the priority. Theother actions will be completed after airwaymanagement is assured.

25. Which of theselaboratoryresultsrequires themost rapidaction by thenurse who iscaring for apatient whosuffered a largeburn 48 hoursago?

Serum potassium 6.2 mEq/L

rationale:Hyperkalemia can lead to fatal bradycardiaand indicates that the patient requirescardiac monitoring and immediatetreatment to lower the potassium level. Theother laboratory values also are abnormaland require changes in treatment, but theyare not as immediately life threatening asthe elevated potassium level.

26. Which of thesemedicationsthat areprescribed asneeded for apatient whohas partialthicknessburns will bebest for thenurse to usebefore wounddebridement?

hydromorphone (Dilaudid)

rationale:Opioid pain medications are the bestchoice for pain control. The othermedications are used as adjuvants toenhance the effect of opioids.

27. Which of these nursing actions should be donefirst for a patient who has suffered a burninjury while working on an electrical powerline?

Stabilize the cervical spine.

rationale:Cervical spine injuries are commonly associated with electrical burns. Thereforestabilization of the cervical spine takes precedence after airway management. Theother actions also are included in the emergent care after electrical burns, but themost important action is to avoid spinal cord injury.

28. Which of these patients is most appropriatefor the burn unit charge nurse to assign to anRN staff nurse who has floated from thehospital medical unit?

A 34-year-old patient who has a weight loss of 15% from admission and requiresenteral feedings and parenteral nutrition (PN)

rationale:An RN from a medical unit would be familiar with malnutrition and withadministration and evaluation of response to enteral feedings and PN. The otherpatients require burn assessment and care that is more appropriate for staff whoregularly care for burned patients.

29. Which of these snacks will be best for thenurse to offer to a patient with burns covering40% total body surface area (TBSA) who is inthe acute phase of burn treatment?

Chocolate milkshake

rationale:A patient with a burn injury needs high protein and calorie food intake, and themilkshake is the highest in these nutrients. The other choices are not as nutrient-dense as the milkshake.