BURNS NURSING QUESTIONS AND ANSWERS ELABORATIONS
When assessing a patient who spilled hot oil on the right leg and foot, the nurse
notes that the skin is dry, pale, hard skin. The patient states that the burn is not
painful. What term would the nurse use to document the burn depth?
Answers :full thickness skin destruction
with full thickness skin destruction the appearance is what?
Answers :pale and dry or leathery and the area is painless because of the
associated nerve destruction. Erythema, swelling, and blisters point to a deep
partial-thickness burn.
superficial partial thickness burns the appearance is what?
Answers :red, but no blisters are present. First-degree burns exhibit erythema,
blanching, and pain.
On admission to the burn unit, a patient with an approximate 25% total body
surface area (TBSA) burn has the following initial laboratory results: Hct 58%,
Hgb 18.2 mg/dL, serum K+ 4.9 mEq/L, and serum Na+ 135 mEq/L. Which action
will the nurse anticipate taking now?
Answers :Increase the rate of the ordered IV solution. The patient's laboratory data
show hemoconcentration, which may lead to a decrease in blood flow to the
microcirculation unless fluid intake is increased. Because the hematocrit and
hemoglobin are elevated, a transfusion is inappropriate, although transfusions may
be needed after the emergent phase once the patient's fluid balance has been
restored. On admission to a burn unit, the urine output would be monitored more
often than every 4 hours; likely every1 hour.
A patient is admitted to the burn unit with burns to the head, face, and hands.
Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no
wheezes are audible. What is the best action for the nurse to take?
, Answers :Notify the health care provider and prepare for endotracheal intubation.
The patient's history and clinical manifestations suggest airway edema and the
health care provider should be notified immediately, so that intubation can be done
rapidly. Placing the patient in a more upright position or having the patient cough
will not address the problem of airway edema. Continuing to monitor is
inappropriate because immediate action should occur.
A patient with severe burns has crystalloid fluid replacement ordered using the
Parkland formula. The initial volume of fluid to be administered in the first 24
hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first
8 hours, what rate should the nurse infuse the IV fluids?
Answers :938 mL/hour
Parkland fluid replacement formula; the first 8 hours you administer how much
fluid?
Answers :Half of the fluid
Parkland fluid replacement formula: the remaining 16 hours how much fluid is
administered?
Answers :half the fluid
During the emergent phase of burn care, which assessment will be most useful in
determining whether the patient is receiving adequate fluid infusion?
Answers :Measure hourly urine output.
A patient has just been admitted with a 40% total body surface area (TBSA) burn
injury. To maintain adequate nutrition, the nurse should plan to take which action?
Answers :Insert a feeding tube and initiate enteral feedings.
, While the patient's full-thickness burn wounds to the face are exposed, what is the
best nursing action to prevent cross contamination?
Answers :Wear gowns, caps, masks, and gloves during all care of the patient.
A nurse is caring for a patient who has burns of the ears, head, neck, and right arm
and hand. The nurse should place the patient in which position?
Answers :Elevate the right arm and hand on pillows and extend the fingers. The
right hand and arm should be elevated to reduce swelling and the fingers extended
to avoid flexion contractures (even though this position may not be comfortable for
the patient). The patient with burns of the ears should not use a pillow for the head
because this will put pressure on the ears, and the pillow may stick to the ears.
Patients with neck burns should not use a pillow because the head should be
maintained in an extended position in order to avoid contractures.
A patient with circumferential burns of both legs develops a decrease in dorsalis
pedis pulse strength and numbness in the toes. Which action should the nurse take?
Answers :Notify the health care provider. The decrease in pulse in a patient with
circumferential burns indicates decreased circulation to the legs and the need for an
escharotomy.
Esomeprazole (Nexium) is prescribed for a patient who incurred extensive burn
injuries 5 days ago. Which nursing assessment would best evaluate the
effectiveness of the medication?
Answers :Stools for occult blood. H2 blockers and proton pump inhibitors are
given to prevent Curling's ulcer in the patient who has suffered burn injuries.
Proton pump inhibitors usually do not affect bowel sounds, stool frequency, or
appetite.
The nurse is reviewing the medication administration record (MAR) on a patient
with partial-thickness burns. Which medication is best for the nurse to administer
before scheduled wound debridement?
When assessing a patient who spilled hot oil on the right leg and foot, the nurse
notes that the skin is dry, pale, hard skin. The patient states that the burn is not
painful. What term would the nurse use to document the burn depth?
Answers :full thickness skin destruction
with full thickness skin destruction the appearance is what?
Answers :pale and dry or leathery and the area is painless because of the
associated nerve destruction. Erythema, swelling, and blisters point to a deep
partial-thickness burn.
superficial partial thickness burns the appearance is what?
Answers :red, but no blisters are present. First-degree burns exhibit erythema,
blanching, and pain.
On admission to the burn unit, a patient with an approximate 25% total body
surface area (TBSA) burn has the following initial laboratory results: Hct 58%,
Hgb 18.2 mg/dL, serum K+ 4.9 mEq/L, and serum Na+ 135 mEq/L. Which action
will the nurse anticipate taking now?
Answers :Increase the rate of the ordered IV solution. The patient's laboratory data
show hemoconcentration, which may lead to a decrease in blood flow to the
microcirculation unless fluid intake is increased. Because the hematocrit and
hemoglobin are elevated, a transfusion is inappropriate, although transfusions may
be needed after the emergent phase once the patient's fluid balance has been
restored. On admission to a burn unit, the urine output would be monitored more
often than every 4 hours; likely every1 hour.
A patient is admitted to the burn unit with burns to the head, face, and hands.
Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no
wheezes are audible. What is the best action for the nurse to take?
, Answers :Notify the health care provider and prepare for endotracheal intubation.
The patient's history and clinical manifestations suggest airway edema and the
health care provider should be notified immediately, so that intubation can be done
rapidly. Placing the patient in a more upright position or having the patient cough
will not address the problem of airway edema. Continuing to monitor is
inappropriate because immediate action should occur.
A patient with severe burns has crystalloid fluid replacement ordered using the
Parkland formula. The initial volume of fluid to be administered in the first 24
hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first
8 hours, what rate should the nurse infuse the IV fluids?
Answers :938 mL/hour
Parkland fluid replacement formula; the first 8 hours you administer how much
fluid?
Answers :Half of the fluid
Parkland fluid replacement formula: the remaining 16 hours how much fluid is
administered?
Answers :half the fluid
During the emergent phase of burn care, which assessment will be most useful in
determining whether the patient is receiving adequate fluid infusion?
Answers :Measure hourly urine output.
A patient has just been admitted with a 40% total body surface area (TBSA) burn
injury. To maintain adequate nutrition, the nurse should plan to take which action?
Answers :Insert a feeding tube and initiate enteral feedings.
, While the patient's full-thickness burn wounds to the face are exposed, what is the
best nursing action to prevent cross contamination?
Answers :Wear gowns, caps, masks, and gloves during all care of the patient.
A nurse is caring for a patient who has burns of the ears, head, neck, and right arm
and hand. The nurse should place the patient in which position?
Answers :Elevate the right arm and hand on pillows and extend the fingers. The
right hand and arm should be elevated to reduce swelling and the fingers extended
to avoid flexion contractures (even though this position may not be comfortable for
the patient). The patient with burns of the ears should not use a pillow for the head
because this will put pressure on the ears, and the pillow may stick to the ears.
Patients with neck burns should not use a pillow because the head should be
maintained in an extended position in order to avoid contractures.
A patient with circumferential burns of both legs develops a decrease in dorsalis
pedis pulse strength and numbness in the toes. Which action should the nurse take?
Answers :Notify the health care provider. The decrease in pulse in a patient with
circumferential burns indicates decreased circulation to the legs and the need for an
escharotomy.
Esomeprazole (Nexium) is prescribed for a patient who incurred extensive burn
injuries 5 days ago. Which nursing assessment would best evaluate the
effectiveness of the medication?
Answers :Stools for occult blood. H2 blockers and proton pump inhibitors are
given to prevent Curling's ulcer in the patient who has suffered burn injuries.
Proton pump inhibitors usually do not affect bowel sounds, stool frequency, or
appetite.
The nurse is reviewing the medication administration record (MAR) on a patient
with partial-thickness burns. Which medication is best for the nurse to administer
before scheduled wound debridement?
