Chapter 55. Nursing Care of Patients With Burns My Nursing Test Banks

Chapter 55. Nursing Care of Patients With Burns

Multiple Choice
Identify the choice that best completes the statement or answers the question.

____ 1. The nurse is at the scene of a fire caring for a patient with a thermal burn on the face, chest, and abdomen. What action should the nurse perform first?
a. Ensure an open airway.
b. Cover the burns with sterile dressings.
c. Wash the burn gently with dilute antiseptic.
d. Pour cool, clean water over the burned areas.
____ 2. The nurse is caring for a patient with burns covering the entire surface of both arms and the anterior trunk. Approximately what percentage of the patients body surface area has been affected?
a. 18%
b. 27%
c. 36%
d. 45%
____ 3. The nurse is caring for a patient in the initial phase of treatment for a partial-thickness burn. The patient has been stabilized, with blood pressure 140/88 mm Hg, pulse 78 beats/min, respirations 22 breaths/min, and temperature 97.4F (36.3C). Which new assessment finding should be immediately communicated to the health care provider (HCP)?
a. Report of increasing pain
b. Temperature 99F (37.2C)
c. Serum-filled blister formation
d. Blood pressure 122/74 mm Hg
____ 4. The nurse is caring for a patient who is 2 days post-inhalation burn injury from a house fire. Which outcome best indicates that nursing interventions for impaired gas exchange have been effective?
a. PaCO2 is 56 mm Hg.
b. The patient is afebrile.
c. The patient is alert and oriented.
d. Peripheral pulses are present and strong.
____ 5. A patient is having a surgical procedure done to promote peripheral tissue perfusion in an extremity with full-thickness circumferential burns. What term should the nurse use to document this procedure?
a. Excision
b. Skin graft
c. Dbridement
d. Escharotomy
____ 6. The nurse is caring for a patient who is receiving fluid replacement after being burned on 37% of the body. Nursing assessment reveals a blood pressure of 80/60 mm Hg, heart rate of 120 beats/min, and urine output of 10 mL over the past hour. After reporting these findings, which order should the nurse expect to be prescribed for this patient?
a. Discontinue the IV fluid infusion.
b. Change the IV fluid to dextrose and water.
c. Increase the amount of IV fluid administered per hour.
d. Decrease the amount of IV fluid administered per hour.
____ 7. The nurse is providing wound care to a patients skin graft donor sites used for burn treatment. For which type of wound is this nurse providing care?
a. Skin tear
b. Full thickness
c. Split thickness
d. Partial thickness
____ 8. The nurse is caring for a patient admitted to the burn unit with burns to 45% of the body. After 3 days, the nurse notes that the patients temperature is newly elevated at 100.2F (37.9C), and the patient exhibits new-onset agitation and confusion. What should the nurse do first?
a. Increase oral fluids to 3000 mL/day.
b. Notify the registered nurse (RN) or primary care provider.
c. Monitor the patient for further changes in mental status.
d. Administer a prn dose of acetaminophen (Tylenol) for the fever.
____ 9. A patient is admitted to the emergency department with chemical burns to the chest and abdomen. The RN immediately begins a sterile saline lavage. What should the licensed practical nurse (LPN) do to assist during this procedure?
a. Apply a neutralizing agent.
b. Apply ice to the burned area.
c. Remove the patients clothing.
d. Prepare intravenous morphine for administration by the RN.
____ 10. The nurse is caring for a patient 3 days following a split-thickness burn injury from a fire. Which observation indicates that nursing interventions to promote cardiac output have been effective?
a. Blood pressure is 128/66 mmHg.
b. Radial pulses are thready at 112/min.
c. Urine output is 1050 mL in 24 hours.
d. Patient weight is 4 pounds less than admission weight.
____ 11. A patient is diagnosed with superficial partial-thickness burns. How many days should the nurse instruct the patient that these burns will need to heal?
a. 1 to 5
b. 7 to 10
c. 14 to 21
d. 28 to 45
____ 12. A patient has burns on both legs and in the genital/perineum area. What is this patients percentage of burned area?
a. 18%
b. 19%
c. 37%
d. 54%
____ 13. A patient wants to know how long it will take to know if a skin graft used to cover a burn site is successful. How many days should the nurse explain as needed for graft vascularization to occur?
a. 1 to 2
b. 3 to 5
c. 7 to 9
d. 11 to 13
____ 14. The nurse notes that a patient with full thickness burns has an increase in hematocrit level. What should the nurse realize is causing this change in laboratory value?
a. Loss of intravascular fluid
b. Destruction of blood vessels
c. Increased function of platelets
d. Migration of white blood cells
____ 15. A patient with a deep partial thickness burn is prescribed wet to dry gauze dressings. Which type of debridement is the nurse performing with this dressing?
a. Surgical
b. Chemical
c. Mechanical
d. Escharotomy
Multiple Response
Identify one or more choices that best complete the statement or answer the question.

____ 16. The nurse is caring for a patient who sustained a partial-thickness burn to the face. Which assessment findings should the nurse expect? (Select all that apply.)
a. Blisters
b. Charred skin
c. White patches
d. Bright red color
e. Leathery character
f. Blanching when touched
____ 17. The nurse is assisting with the care of a patient admitted to the emergency department with chemical burns across the chest and hands. Which actions should be included in the plan of care? (Select all that apply.)
a. Apply ice packs to burn sites.
b. Remove all contaminated clothing.
c. Cover the patient with a clean sheet.
d. Apply neutralizing agent to burn area.
e. Obtain a history of the event and burning agent.
f. Provide copious tepid water lavage for 20 minutes.
____ 18. The nurse is caring for a patient with extensive burns. For which systemic responses to the burn should the nurse monitor the patient? (Select all that apply.)
a. Hypovolemia
b. Peptic ulceration
c. Decreased metabolism
d. Increased platelet function
e. Increased oxygen consumption
f. Depression of immunoglobulins
____ 19. The nurse is preparing a patient with 46% total body surface area burned for graft placement. Which anatomical locations should the nurse expect to have a lower rate of graft success than other areas of the body? (Select all that apply.)
a. Axillae
b. Buttocks
c. Perineum
d. Forearms
e. Abdomen
f. Joint areas
____ 20. A victim of a fire in a manufacturing plant is brought to the emergency department. The HCP suspects this victim has sustained an inhalation injury. Which tests should the nurse expect to be prescribed for this patient? (Select all that apply.)
a. Chest x-ray
b. Bronchoscopy
c. Arterial blood gases
d. CT scan of the thorax
e. Carboxyhemoglobin level
____ 21. The nurse is preparing to apply dressings to a patients partial-thickness burn wounds. What should the nurse keep in mind when applying these dressings? (Select all that apply.)
a. Wrap digits as one dressing.
b. Elevate affected extremities.
c. Limit the amount of dressing bulk.
d. Wrap extremities from distal to proximal.
e. Double the estimated size of dressing material.
____ 22. A patient with a partial thickness burn wound is prescribed synthetic dressings. What should the nurse explain to the patient about this type of dressing? (Select all that apply.)
a. Easier to store
b. Cost less to use
c. Readily available
d. Come in various shapes
e. Contain antimicrobial substances

Chapter 55. Nursing Care of Patients With Burns
Answer Section

MULTIPLE CHOICE

1. ANS: A
Care should be provided according to the ABCs or airway, breathing, and circulation. B. C. D. The burn wound takes a lower priority to the ABCs (airway, breathing, circulation) of trauma resuscitation.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

2. ANS: C
According to the Rule of Nines, each arm is 9% and the anterior trunk is 18% for a total of 36%. A. B. D. These are inaccurate calculations using the Rule of Nines.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

3. ANS: D
A patient with a burn is at risk for fluid volume deficit, and a dropping blood pressure, even though it is still within normal limits, could be an early sign. A. B. Temperature and pain are concerns but are not immediately life threatening. C. Blister formation is expected.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

4. ANS: C
Poor oxygenation results in reduced level of consciousness and confusion, so an alert and oriented patient likely has safe gas exchange. B. D. Peripheral pulses and temperature are not directly affected by gas exchange. A. A PaCO2 of 56 mm Hg shows poor gas exchange.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Evaluation

5. ANS: D
If the patient has a circumferential burn an increase in tissue pressure secondary to tissue edema occurs. The burn then acts like a tourniquet, impeding arterial and venous flow. An escharotomy is immediately necessary to relieve this pressure. An escharotomy is a linear excision through the eschar to the superficial fat that allows for expansion of the skin and return of blood flow. A. Excision refers to cutting something out. B. A skin graft places new skin over a burn site. C. Dbridement removes dead tissue.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

6. ANS: C
In the first 48 hours after a burn, fluid shifts lead to hypovolemia and, if untreated, hypovolemic shock. Low blood pressure, elevated pulse, and low urine output indicate hypovolemia, so the nurse should anticipate increasing IV fluids. A. D. Decreasing or discontinuing fluids is inappropriate. B. Dextrose and water is hypotonic and will not maintain circulating volume.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

7. ANS: D
A donor site is considered a partial-thickness wound. A. A skin tear is accidental. B. C. Full and split thicknesses describe different types of grafts, not donor sites.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

8. ANS: B
The nurse should continually assess for and report signs and symptoms of sepsis: temperature elevation, change in sensorium, changes in vital signs and bowel sounds, decreased output, and positive blood/wound cultures. A rise in temperature should be reported. A. C. D. Further monitoring, Tylenol, and fluids may also be appropriate but only after the HCP determines the cause of the change and provides recommendations.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

9. ANS: C
Clothing can retain heat and thermal agents, therefore increasing depth of injury, and so should be removed as quickly as possible. B. Ice can reduce circulation and impede healing: cool water or saline should be used to cool and flush the area. D. Morphine is important but not as important as stopping the burning. A. A neutralizing agent is not used.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

10. ANS: A
Patients with burn injury are at risk for fluid volume deficit and decreased cardiac output. The blood pressure reading is normal and indicates adequate cardiac output. C. The urinary output is low and indicates fluid deficit because urine output should be maintained at least 50 mL/hr (1200 mL/24 hours). B. Thready peripheral pulses are indicative of low cardiac output. D. Weight loss could indicate fluid loss.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Evaluation

11. ANS: B
In general, superficial partial-thickness burns usually heal in 7 to 10 days. C. Deep partial-thickness burns may take up to 3 weeks. A. Burns need longer than 1 to 5 days to heal. D. Burns that need longer than 3 weeks to heal may need skin grafting.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

12. ANS: C
Each leg is 18%, and the perineum is 1%, equaling 37%. A. B. D. These are inaccurate calculations for the percentage of body surface area burned.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

13. ANS: B
Graft take, or vascularization, is complete in about 3 to 5 days. A. It takes longer than 1 to 2 days for vascularization to occur. C. D. Vascularization should occur before 7 days and does not take up to 13 days.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

14. ANS: A
A burn is followed by an initial decrease in cardiac output, which is further compromised by the loss of circulating plasma volume. In the first 48 hours after a burn, fluid shifts lead to hypovolemia and, if untreated, hypovolemic shock. Loss of intravascular fluid causes a relative increase in hematocrit. B. C. D. The increase in hematocrit level is not caused by destruction of red blood cells, increased function of platelets, or migration of white blood cells.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

15. ANS: C
Mechanical debridement can involve the use of scissors and forceps to manually excise loose nonviable tissue, or the use of wet-to-moist or wet-to-dry fine-mesh gauze dressings. A. Surgical debridement is the excision of full-thickness and deep partial-thickness burns. B. Chemical debridement involves the use of a proteolytic enzymatic debriding agent that digests necrotic tissue. D. An escharotomy is a linear excision through the eschar to the superficial fat that allows for expansion of the skin and return of blood flow or chest expansion.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

MULTIPLE RESPONSE

16. ANS: A, D, F
A partial-thickness burn is bright red to pink, blanches to touch, and has serum-filled blisters. C. E. Leathery or white describe full-thickness burns. B. A charred burn needs further assessment.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

17. ANS: B, C, E, F
Initiate immediate copious tepid water lavage for 20 minutes for all chemical burns, along with simultaneous removal of contaminated clothing. Cover the patient with a clean sheet and obtain a history of the burning agent. D. Do not neutralize chemical because this takes too much time, and the resulting reaction may generate heat and cause further skin injury. A. Do not apply ice.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

18. ANS: A, B, E, F
Following a major burn, increased capillary permeability leads to the leakage of plasma and proteins into the tissue, resulting in the formation of edema and loss of intravascular volume. C. Metabolic demands are very high in patients with burns, which in turn increases oxygen consumption. D. Intense heat decreases platelet function and half-life. With the skin destroyed, the body loses its first line of defense against infection. Major burns also cause a depression of the immunoglobulins IgA, IgG, and IgM. Peptic ulcers can occur due to decreased gastric motility and the stress response.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

19. ANS: A, B, C, F
The perineum, axillae, buttocks, and joints are generally poor areas for graft success. D. E. Factors promoting graft success are smooth contoured areas, adequate hemostasis, and good nutritional status.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

20. ANS: B, C, E
If an inhalation injury is suspected, arterial blood gases, bronchoscopy, and carboxyhemoglobin levels are done. A. D. A chest x-ray is not immediately performed for a suspected inhalation injury. D. A CT scan of the thorax may or may not be indicated for this type of injury.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

21. ANS: B, C, D
General principles for dressings include elevating the affected extremities, limiting the bulk of the dressing to facilitate range of motion, and wrapping extremities from distal to proximal to promote venous return. A. Never wrap skin-to-skin surfaces. E. The size of the dressings should be based on the size of the wounds, absorption, protection, and type of debridement.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

22. ANS: A, B, C, D
Synthetic dressings are used in the management of partial-thickness burns and donor sites. Synthetic dressings are more readily available, less costly, and easier to store than biological dressings. They are made from a variety of materials and come in many different sizes and shapes. E. Most of these dressings contain no antimicrobial agents.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

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