Question 1

The nurse monitors for which assessment findings in the patient admitted with superficial partial-thickness burns over both anterior lower arms?

Accepted Answer

Superficial partial-thickness burns affect the epidermis and part of the dermis. They typically present with open or closed blisters, mild edema, and the skin easily blanches when pressure is applied. This type of burn is painful and sensitive to air and temperature because nerve endings are exposed.

Question 2

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?

Accepted Answer

B

Question 3

A victim of a house fire is brought to the emergency department for burn treatment. The nurse correlates which assessment to an inhalation injury?

Accepted Answer

C

Question 4

A patient with several deep partial-thickness burns asks how long it will take for the burn to heal. What is the nurse's best response?

Accepted Answer

Deep partial-thickness burns typically take more than 2 weeks to heal due to the extent of skin damage.

Question 5

A patient recovering from 25% total body surface area burns has a low-grade fever. What actions are the priority for the nurse to reduce this patient's risk of developing an infection?

Accepted Answer

The answer of A patient recovering from 25% total body...

Question 6

The nurse is caring for a patient who sustained electrical burns. What is the rationale for monitoring this patient for compartment syndrome?

Accepted Answer

The answer of The nurse is caring for a patient...

Question 7

The nurse provides care to a patient who sustained burns on 75% of the body. Which data requires the nurse to notify the healthcare provider?

Accepted Answer

A blood pressure of 96/50 mm Hg in a patient with 75% body burns is concerning for hypovolemia or shock, requiring immediate notification of the healthcare provider.

Question 8

In providing care to a victim of a car fire who is confused, dizzy, and nauseated, the nurse recognizes the need for which diagnostic test to determine if this patient is experiencing carbon monoxide poisoning?

Accepted Answer

Carboxyhemoglobin level is the specific test used to diagnose carbon monoxide poisoning, as it measures the amount of carbon monoxide bound to hemoglobin in the blood.

Question 9

A patient with 55% total body surface area burned received two-thirds of the required fluid resuscitation. For which potential problem should the nurse prepare to provide care to this patient?

Accepted Answer

The answer of A patient with 55% total body surface...

Question 10

The nurse is caring for a patient with 45% total body surface area thermal burns. The nurse monitors for which laboratory result?

Accepted Answer

In patients with significant burns, cell destruction leads to the release of intracellular potassium into the bloodstream, causing hyperkalemia (increased potassium levels).

Question 11

The nurse is preparing an educational tool to instruct community members on burn prevention. What does the nurse include as the most common injury in children younger than age 5?

Accepted Answer

Scald injuries are the most common type of burn injury among children younger than age 5, often occurring from hot liquids or steam.

Question 12

The nurse administers a large dose of the prescribed opioid analgesic in preparation for a dressing change for a patient with significant burn injury. What is the nurse's priority in this situation?

Accepted Answer

The priority is to ensure patient safety by having a bag and mask at the bedside in case of respiratory depression, a potential side effect of opioid analgesics.

Question 13

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?

Accepted Answer

Duodenal tube feedings are most effective because they allow for continuous nutrition delivery directly to the small intestine, bypassing any gastric issues and ensuring adequate nutrient absorption, which is crucial for burn patients with high metabolic demands.

Question 14

In providing care to a patient admitted with a suspected inhalation injury, what nursing action in the priority?

Accepted Answer

Administering 100% humidified oxygen is the priority nursing action for a patient with a suspected inhalation injury to ensure adequate oxygenation and to help reduce the effects of smoke inhalation on the airway and lungs.

Question 15

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?

Accepted Answer

The answer of The nurse provides care to a patient...

Question 16

A patient presents to the emergency room seeking treatment for radiation burns. What needs to be considered before providing care to this patient?

Accepted Answer

The type, dose, and length of exposure to radiation are crucial factors in determining the severity of radiation burns and the appropriate treatment plan. These factors influence the extent of damage and the necessary medical interventions.

Question 17

The nurse is evaluating care provided to a patient with burns during the emergent phase. Which data indicate that additional fluid resuscitation is required?

Accepted Answer

Central venous pressure (CVP) of 2 mm Hg is low, indicating hypovolemia and the need for additional fluid resuscitation.

Question 18

In caring for patient with 50% total body surface area burns, the nurse correlates which finding to resolution of burn shock?

Accepted Answer

Urine output is a key indicator of renal perfusion and fluid balance. In the context of burn shock resolution, an adequate urine output (0.5-1 mL/kg/hr for adults) suggests effective circulatory volume resuscitation and stabilization, indicating that the patient is moving out of the shock phase. In this case, 800 mL over 2 hours is considered adequate for most adults, suggesting improved renal perfusion and fluid status.

Question 19

A patient with deep partial-thickness wounds is receiving enzymatic debridement. What assessment data does the nurse correlate to successful wound care treatment?

Accepted Answer

Separation of eschar is a sign that enzymatic debridement is effectively removing dead tissue from the wound, which is essential for the healing process. Enzymatic debridement specifically targets necrotic tissue, and the separation of eschar indicates that the dead tissue is being broken down and removed, allowing for the growth of healthy tissue.

Question 20

The nurse is assisting with the secondary survey of a patient with 50% total body surface area electrical burns. Which test would be a priority for this patient?

Accepted Answer

A 12-lead electrocardiogram (ECG) is a priority for a patient with extensive electrical burns, as electrical injuries can cause cardiac arrhythmias and other heart-related issues. Monitoring the heart's electrical activity is crucial for detecting and managing these potential complications.

Quiz 51: Coordinating Care for Patients With Burns