NURS 432 Burns Review questions with accurate
answers
1. A nurse cares for a client with burn injuries during the resuscitation
phase. Which actions are priorities during this phase? (Select all that
apply.)
a. Administer analgesics.
b. Prevent wound infections.
c. Provide fluid replacement.
d. Decrease core temperature.
e. Initiate physical therapy. Ans✓✓✓ ANS: A, B, C
Nursing priorities during the resuscitation phase include securing the
airway, supporting circulation and organ perfusion by fluid replacement,
keeping the client comfortable with analgesics, preventing infection
through careful wound care, maintaining body temperature, and
providing emotional support. Physical therapy is inappropriate during
the resuscitation phase but may be initiated after the client has been
stabilized.
1. An emergency room nurse cares for a client admitted with a 50% burn
injury at 10:00 this morning. The client weighs 90 kg. Using the
Parkland formula, calculate the rate at which the nurse should infuse
intravenous fluid resuscitation when started at noon. (Record your
answer using a whole number.) _____ mL/hr Ans✓✓✓ 1500 mL/hr
The Parkland formula is 4 mL/kg/% total body surface area burn. This
client needs 18,000 mL of fluid during the first 24 hours postburn. Half
of the calculated fluid replacement needs to be administered during the
first 8 hours after injury, and half during the next 16 hours. This client
was burned at 10:00 AM, and fluid was not started until noon.
,Therefore, 9000 mL must be infused over the next 6 hours at a rate of
1500 mL/hr to meet the criteria of receiving half the calculated dose
during the first 8 postburn hours.
1. The optimal measurement of intravascular fluid status during the
immediate fluid resuscitation phase of burn treatment is:
a.
blood urea nitrogen.
b.
daily weight.
c.
hourly intake and urine output.
d.
serum potassium. Ans✓✓✓ ANS: C
,During initial fluid resuscitation, urine output helps guide fluid
resuscitation needs. Measuring hourly intake and output is most
effective in determining the needs for additional fluid infusion than is
urine output alone. Blood urea nitrogen may be used to monitor volume
status, but it is affected by the hypermetabolic state seen after burns, so
it is not the optimal measure of intravascular fluid status. Daily weight
measures overall volume status, not just intravascular volume. Serum
potassium is released with tissue damage and thus is not the optimum
measure of intravascular fluid status.
1. The registered nurse assigns a client who has an open burn wound to a
licensed practical nurse (LPN). Which instruction should the nurse
provide to the LPN when assigning this client?
a. Administer the prescribed tetanus toxoid vaccine.
b. Assess the clients wounds for signs of infection.
c. Encourage the client to breathe deeply every hour.
d. Wash your hands on entering the clients room. Ans✓✓✓ ANS: D
Infection can occur when microorganisms from another person or from
the environment are transferred to the client. Although all of the
interventions listed can help reduce the risk for infection, handwashing
is the most effective technique for preventing infection transmission.
1. Which of the following statements about the pain management of a
burn victim are true? (Select all that apply.)
a.
, Additional pain medication may be needed because of rapid body
metabolism.
b.
Pain medication should be given before procedures such as debridement,
dressing changes, and physical therapy.
c.
Patients with a history of drug and alcohol abuse will require higher
doses of pain medication.
d.
The intramuscular route is preferred for pain medication administration.
Ans✓✓✓ ANS: A, B, C
The rapid metabolism associated with burn injury may require additional
pain medication. Many of the procedures associated with burn wounds
are painful, such as dressing changes. Adequate pain medication should
be given prior to the procedures. Edema in burned patients alters the
absorption of medications that are injected intramuscularly; therefore,
drugs must be administered by the IV route.
answers
1. A nurse cares for a client with burn injuries during the resuscitation
phase. Which actions are priorities during this phase? (Select all that
apply.)
a. Administer analgesics.
b. Prevent wound infections.
c. Provide fluid replacement.
d. Decrease core temperature.
e. Initiate physical therapy. Ans✓✓✓ ANS: A, B, C
Nursing priorities during the resuscitation phase include securing the
airway, supporting circulation and organ perfusion by fluid replacement,
keeping the client comfortable with analgesics, preventing infection
through careful wound care, maintaining body temperature, and
providing emotional support. Physical therapy is inappropriate during
the resuscitation phase but may be initiated after the client has been
stabilized.
1. An emergency room nurse cares for a client admitted with a 50% burn
injury at 10:00 this morning. The client weighs 90 kg. Using the
Parkland formula, calculate the rate at which the nurse should infuse
intravenous fluid resuscitation when started at noon. (Record your
answer using a whole number.) _____ mL/hr Ans✓✓✓ 1500 mL/hr
The Parkland formula is 4 mL/kg/% total body surface area burn. This
client needs 18,000 mL of fluid during the first 24 hours postburn. Half
of the calculated fluid replacement needs to be administered during the
first 8 hours after injury, and half during the next 16 hours. This client
was burned at 10:00 AM, and fluid was not started until noon.
,Therefore, 9000 mL must be infused over the next 6 hours at a rate of
1500 mL/hr to meet the criteria of receiving half the calculated dose
during the first 8 postburn hours.
1. The optimal measurement of intravascular fluid status during the
immediate fluid resuscitation phase of burn treatment is:
a.
blood urea nitrogen.
b.
daily weight.
c.
hourly intake and urine output.
d.
serum potassium. Ans✓✓✓ ANS: C
,During initial fluid resuscitation, urine output helps guide fluid
resuscitation needs. Measuring hourly intake and output is most
effective in determining the needs for additional fluid infusion than is
urine output alone. Blood urea nitrogen may be used to monitor volume
status, but it is affected by the hypermetabolic state seen after burns, so
it is not the optimal measure of intravascular fluid status. Daily weight
measures overall volume status, not just intravascular volume. Serum
potassium is released with tissue damage and thus is not the optimum
measure of intravascular fluid status.
1. The registered nurse assigns a client who has an open burn wound to a
licensed practical nurse (LPN). Which instruction should the nurse
provide to the LPN when assigning this client?
a. Administer the prescribed tetanus toxoid vaccine.
b. Assess the clients wounds for signs of infection.
c. Encourage the client to breathe deeply every hour.
d. Wash your hands on entering the clients room. Ans✓✓✓ ANS: D
Infection can occur when microorganisms from another person or from
the environment are transferred to the client. Although all of the
interventions listed can help reduce the risk for infection, handwashing
is the most effective technique for preventing infection transmission.
1. Which of the following statements about the pain management of a
burn victim are true? (Select all that apply.)
a.
, Additional pain medication may be needed because of rapid body
metabolism.
b.
Pain medication should be given before procedures such as debridement,
dressing changes, and physical therapy.
c.
Patients with a history of drug and alcohol abuse will require higher
doses of pain medication.
d.
The intramuscular route is preferred for pain medication administration.
Ans✓✓✓ ANS: A, B, C
The rapid metabolism associated with burn injury may require additional
pain medication. Many of the procedures associated with burn wounds
are painful, such as dressing changes. Adequate pain medication should
be given prior to the procedures. Edema in burned patients alters the
absorption of medications that are injected intramuscularly; therefore,
drugs must be administered by the IV route.
