Sole Ch 21 - burns exam 5 2021/2022 questions with complete solutions

The optimal measurement of intravascular fluid status during the immediate fluid resuscitation phase of burn treatment is a) BUN b) daily weight c) hourly intake and urine output d) serum potassium 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. In patients with extensive burns, edema occurs in both burned and unburned areas because of a) catecholamine-induced vasoconstriction b) decreased GFR c) increased capillary permeability d) loss of integument barrier C Capillary permeability is altered in burns beyond the area of tissue damage, resulting in significant shift of proteins, fluid, and electrolytes resulting in edema (third-spacing). 00:15 01:16 Tissue damage from burn injury activates an inflammatory response that increases the patient's risk for a) AKI b) ARDS c) infection d) stress ulcers C The loss of skin as the primary barrier against microorganisms and activation of the inflammatory response cascades results in immunosuppression, placing the patient at an increased risk of infection. The nurse is caring for a burn-injured patient who weighs 154 pounds, and the burn injury covers 50% of his body surface area. The nurse calculates the fluid needs for the first 24 hours after a burn injury using a standard fluid resuscitation formula of 4 mL/kg/% burn of intravenous (IV) fluid for the first 24 hours. The nurse plans to administer what amount of fluid in the first 24 hours? a) 2800 mL b) 7000 mL c) 14 L d) 28 L C 154 pounds/2.2 = 70 kg 4 × 70 kg × 50 = 14,000 mL, or 14 liters. The nurse is caring for a patient who has circumferential full-thickness burns of his forearm. A priority in the plan of care is a) to keep the extremity in a dependent position b) active or passive ROM exercises every hour c) to prepare for a escharotomy as a prophylactic measure d) to splint the forearm B Special attention is given to circumferential (completely surrounding a body part) full-thickness burns of the extremities. Pressure from bands of eschar or from edema that develops as resuscitation proceeds may impair blood flow to underlying and distal tissue. Therefore, extremities are elevated to reduce edema. Active or passive range-of-motion (ROM) exercises are performed every hour for 5 minutes to increase venous return and to minimize edema. The patient asks the nurse if the placement of the autograft over his full thickness burn will be the only surgical intervention needed to close his wound. The nurse's best response would be: a) "Unfortunately, an autograft skin is a temporary graft and a second surgery will be needed to close the wound." b) "An autograft is a biological dressing that will eventually be replaced by your body generating new tissue." c) "Yes, an autograft will transfer your own skin from one area of your body to cover the burn wound." d) "Unfortunately, autografts frequently do no adhere to burn wounds and a xenograft will be necessary to close the wound." C The autograft is the only permanent method of grafting, and it uses the patient's own tissue to cover the burn wound. A patient admitted with severe burns to his face and hands is showing signs of extreme agitation. The nurse should explore the mechanism of burn injury possibly related to a) excessive alcohol use b) methamphetamine use c) PTSD d) subacute delirium B A vague or inconsistent injury history, burns to the face and hands, and signs of agitation or substance withdrawal should alert the nurse to a potential methamphetamine-related injury. The nurse is caring for patient who has been struck by lightning. Because of the nature of the injury, the nurse assesses the patient for which of the following? a) CNS deficits b) Contractures c) Infection d) Stress ulcers A Lightning injury frequently causes cardiopulmonary arrest. However, of those patients who survive, 70% will have transient central nervous system deficits. The nurse is managing the pain of a patient with burns. The provider has prescribed opiates to be given intramuscularly. The nurse contacts the provider to change the prescription to IV administration because a) IM injections cause additional skin disruption b) burn pain is so severe it required relief by the fastest route available c) hypermetabolism limits effectiveness of medications administered IM d) tissue edema may interfere w/ drug absorption of injectable routes D Edema and impaired circulation of the soft tissue interfere with absorption of medications administered subcutaneously or intramuscularly When paramedics notice singed hairs in the nose of a burn patient, it is recommended that the patient be intubated. What is the reasoning for the immediate intubation? a) Carbon monoxide poisoning always occurs when soot is visible. b) Inhalation injury above the glottis may cause significant edema that obstructs the airway. c) The patient will have a copious amount of mucus that will need to be suctioned. d) The singed hairs and soot in the nostrils will cause dysfunction of cilia in the airways. B In inhalation injury, the airway may become edematous quickly, making intubation difficult. Early intubation is recommended to protect the airway. A patient with a 60% burn in the acute phase of treatment develops a tense abdomen, decreasing urine output, hypercapnia, and hypoxemia. Based on this assessment, the nurse anticipates interventions to evaluate and treat the patient for a) AKI b) ARDS c) intra-abdominal hypertension d) DIC disorder C Intra-abdominal hypertension (IAH) is a serious complication caused by circumferential torso burn injuries or edema from aggressive fluid resuscitation. Signs and symptoms of IAH include tense abdomen, decreased urine output, and worsening pulmonary function. An elderly individual from an assisted-living facility (ALF) presents with severe scald burns to the buttocks and back of the thighs. The caregiver from the ALF accompanies the patient to the emergency department and states that the bath water was "too hot" and that the "patient sat in the water too long." What should the nurse do? a) Ask the caregiver at what temperature the water heater is set in the home. b) Ask the caregiver to step out while examining the patient's burn injury. c) Immediately contact the police to report the suspected elder abuse. d) Ask the caregiver to describe exactly how the injury occurred. B In cases of suspected abuse, especially in vulnerable patients such as children, elderly, and mentally impaired, it is important to assess the injured patient separately from the caregiver.