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? - ANSWER full
thickness skin destruction
with full thickness skin destruction the appearance is what? - ANSWER 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? - ANSWER 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? - ANSWER 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? - ANSWER
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? - ANSWER 938 mL/hour
Parkland fluid replacement formula; the first 8 hours you administer how much fluid?
- ANSWER Half of the fluid
Parkland fluid replacement formula: the remaining 16 hours how much fluid is
administered? - ANSWER 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? - ANSWER
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? -
ANSWER 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? - ANSWER 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? - ANSWER 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?
- ANSWER 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? - ANSWER 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? - ANSWER Hydromorphone (Dilaudid). Opioid pain
medications are the best choice for pain control.
A young adult patient who is in the rehabilitation phase after having deep partial-
thickness face and neck burns has a nursing diagnosis of disturbed body image.
Which statement by the patient indicates that the problem is resolving? - ANSWER
Do you think dark beige makeup foundation would cover this scar on my cheek?"
,The willingness to use strategies to enhance appearance is an indication that the
disturbed body image is resolving.
The nurse caring for a patient admitted with burns over 30% of the body surface
assesses that urine output has dramatically increased. Which action by the nurse
would best ensure adequate kidney function? - ANSWER Continue to monitor the
urine output. The patient's urine output indicates that the patient is entering the acute
phase of the burn injury and moving on from the emergent stage. At the end of the
emergent phase, capillary permeability normalizes and the patient begins to diurese
large amounts of urine with a low specific gravity. Although this may occur at about
48 hours, it may be longer in some patients.
A patient with burns covering 40% total body surface area (TBSA) is in the acute
phase of burn treatment. Which snack would be best for the nurse to offer to this
patient? - ANSWER Vanilla milkshake, A patient with a burn injury needs high
protein and calorie food intake
A patient has just arrived in the emergency department after an electrical burn from
exposure to a high-voltage current. What is the priority nursing assessment? -
ANSWER Extremity movement; All patients with electrical burns should be
considered at risk for cervical spine injury, and assessments of extremity movement
will provide baseline data.
An employee spills industrial acids on both arms and legs at work. What is the
priority action that the occupational health nurse at the facility should take? -
ANSWER the initial action is to remove the chemical from contact with the skin as
quickly as possible. Remove nonadherent clothing, shoes, watches, jewelry, glasses,
or contact lenses (if face was exposed). Flush chemical from wound and surrounding
area with copious amounts of saline solution or water.
A patient who has burns on the arms, legs, and chest from a house fire has become
agitated and restless 8 hours after being admitted to the hospital. Which action
should the nurse take first? - ANSWER Use pulse oximetry to check the oxygen
saturation. Agitation in a patient who may have suffered inhalation injury might
indicate hypoxia, and this should be assessed by the nurse first.
A patient arrives in the emergency department with facial and chest burns caused by
a house fire. Which action should the nurse take first? - ANSWER Auscultate the
patient's lung sounds; A patient with facial and chest burns is at risk for inhalation
injury, and assessment of airway and breathing is the priority. The other actions will
be completed after airway management is assured.
A patient with extensive electrical burn injuries is admitted to the emergency
department. Which prescribed intervention should the nurse implement first? -
, ANSWER Place on cardiac monitor; After an electrical burn, the patient is at risk for
fatal dysrhythmias and should be placed on a cardiac monitor.
Eight hours after a thermal burn covering 50% of a patient's total body surface area
(TBSA) the nurse assesses the patient. Which information would be a priority to
communicate to the health care provider? - ANSWER Urine output is 20 mL per
hour for the past 2 hours; The urine output should be at least 0.5 to 1.0 mL/kg/hr
during the emergent phase, when the patient is at great risk for hypovolemic shock.
The nurse should notify the health care provider because a higher IV fluid rate is
needed. BP during the emergent phase should be greater than 90 systolic, and the
pulse rate should be less than 120. Serous exudate from the burns is expected
during the emergent phase.
A patient who was found unconscious in a burning house is brought to the
emergency department by ambulance. The nurse notes that the patient's skin color
is bright red. Which action should the nurse take first? - ANSWER Place the patient
on 100% oxygen using a non-rebreather mask. The patient's history and skin color
suggest carbon monoxide poisoning, which should be treated by rapidly starting
oxygen at 100%.
he nurse is reviewing laboratory results on a patient who had a large burn 48 hours
ago. Which result requires priority action by the nurse? - ANSWER Serum
potassium 6.1 mEq/L; Hyperkalemia can lead to fatal dysrhythmias and indicates
that the patient requires cardiac monitoring and immediate treatment to lower the
potassium level.
The charge nurse observes the following actions being taken by a new nurse on the
burn unit. Which action by the new nurse would require an intervention by the charge
nurse? - ANSWER The new nurse uses clean latex gloves when applying
antibacterial cream to a burn wound. Sterile gloves should be worn when applying
medications or dressings to a burn.
Which nursing action is a priority for a patient who has suffered a burn injury while
working on an electrical power line? - ANSWER Stabilize the cervical spine.
Cervical spine injuries are commonly associated with electrical burns. Therefore
stabilization of the cervical spine takes precedence after airway management.
Which action will the nurse include in the plan of care for a patient in the
rehabilitation phase after a burn injury to the right arm and chest? - ANSWER Apply
water-based cream to burned areas frequently. Application of water-based
emollients will moisturize new skin and decrease flakiness and itching.
A young adult patient who is in the rehabilitation phase 6 months after a severe face
and neck burn tells the nurse, "I'm sorry that I'm still alive. My life will never be
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? - ANSWER full
thickness skin destruction
with full thickness skin destruction the appearance is what? - ANSWER 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? - ANSWER 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? - ANSWER 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? - ANSWER
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? - ANSWER 938 mL/hour
Parkland fluid replacement formula; the first 8 hours you administer how much fluid?
- ANSWER Half of the fluid
Parkland fluid replacement formula: the remaining 16 hours how much fluid is
administered? - ANSWER 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? - ANSWER
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? -
ANSWER 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? - ANSWER 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? - ANSWER 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?
- ANSWER 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? - ANSWER 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? - ANSWER Hydromorphone (Dilaudid). Opioid pain
medications are the best choice for pain control.
A young adult patient who is in the rehabilitation phase after having deep partial-
thickness face and neck burns has a nursing diagnosis of disturbed body image.
Which statement by the patient indicates that the problem is resolving? - ANSWER
Do you think dark beige makeup foundation would cover this scar on my cheek?"
,The willingness to use strategies to enhance appearance is an indication that the
disturbed body image is resolving.
The nurse caring for a patient admitted with burns over 30% of the body surface
assesses that urine output has dramatically increased. Which action by the nurse
would best ensure adequate kidney function? - ANSWER Continue to monitor the
urine output. The patient's urine output indicates that the patient is entering the acute
phase of the burn injury and moving on from the emergent stage. At the end of the
emergent phase, capillary permeability normalizes and the patient begins to diurese
large amounts of urine with a low specific gravity. Although this may occur at about
48 hours, it may be longer in some patients.
A patient with burns covering 40% total body surface area (TBSA) is in the acute
phase of burn treatment. Which snack would be best for the nurse to offer to this
patient? - ANSWER Vanilla milkshake, A patient with a burn injury needs high
protein and calorie food intake
A patient has just arrived in the emergency department after an electrical burn from
exposure to a high-voltage current. What is the priority nursing assessment? -
ANSWER Extremity movement; All patients with electrical burns should be
considered at risk for cervical spine injury, and assessments of extremity movement
will provide baseline data.
An employee spills industrial acids on both arms and legs at work. What is the
priority action that the occupational health nurse at the facility should take? -
ANSWER the initial action is to remove the chemical from contact with the skin as
quickly as possible. Remove nonadherent clothing, shoes, watches, jewelry, glasses,
or contact lenses (if face was exposed). Flush chemical from wound and surrounding
area with copious amounts of saline solution or water.
A patient who has burns on the arms, legs, and chest from a house fire has become
agitated and restless 8 hours after being admitted to the hospital. Which action
should the nurse take first? - ANSWER Use pulse oximetry to check the oxygen
saturation. Agitation in a patient who may have suffered inhalation injury might
indicate hypoxia, and this should be assessed by the nurse first.
A patient arrives in the emergency department with facial and chest burns caused by
a house fire. Which action should the nurse take first? - ANSWER Auscultate the
patient's lung sounds; A patient with facial and chest burns is at risk for inhalation
injury, and assessment of airway and breathing is the priority. The other actions will
be completed after airway management is assured.
A patient with extensive electrical burn injuries is admitted to the emergency
department. Which prescribed intervention should the nurse implement first? -
, ANSWER Place on cardiac monitor; After an electrical burn, the patient is at risk for
fatal dysrhythmias and should be placed on a cardiac monitor.
Eight hours after a thermal burn covering 50% of a patient's total body surface area
(TBSA) the nurse assesses the patient. Which information would be a priority to
communicate to the health care provider? - ANSWER Urine output is 20 mL per
hour for the past 2 hours; The urine output should be at least 0.5 to 1.0 mL/kg/hr
during the emergent phase, when the patient is at great risk for hypovolemic shock.
The nurse should notify the health care provider because a higher IV fluid rate is
needed. BP during the emergent phase should be greater than 90 systolic, and the
pulse rate should be less than 120. Serous exudate from the burns is expected
during the emergent phase.
A patient who was found unconscious in a burning house is brought to the
emergency department by ambulance. The nurse notes that the patient's skin color
is bright red. Which action should the nurse take first? - ANSWER Place the patient
on 100% oxygen using a non-rebreather mask. The patient's history and skin color
suggest carbon monoxide poisoning, which should be treated by rapidly starting
oxygen at 100%.
he nurse is reviewing laboratory results on a patient who had a large burn 48 hours
ago. Which result requires priority action by the nurse? - ANSWER Serum
potassium 6.1 mEq/L; Hyperkalemia can lead to fatal dysrhythmias and indicates
that the patient requires cardiac monitoring and immediate treatment to lower the
potassium level.
The charge nurse observes the following actions being taken by a new nurse on the
burn unit. Which action by the new nurse would require an intervention by the charge
nurse? - ANSWER The new nurse uses clean latex gloves when applying
antibacterial cream to a burn wound. Sterile gloves should be worn when applying
medications or dressings to a burn.
Which nursing action is a priority for a patient who has suffered a burn injury while
working on an electrical power line? - ANSWER Stabilize the cervical spine.
Cervical spine injuries are commonly associated with electrical burns. Therefore
stabilization of the cervical spine takes precedence after airway management.
Which action will the nurse include in the plan of care for a patient in the
rehabilitation phase after a burn injury to the right arm and chest? - ANSWER Apply
water-based cream to burned areas frequently. Application of water-based
emollients will moisturize new skin and decrease flakiness and itching.
A young adult patient who is in the rehabilitation phase 6 months after a severe face
and neck burn tells the nurse, "I'm sorry that I'm still alive. My life will never be
