Critical care burns

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: 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. DIF: Cognitive Level: Comprehension REF: p. 636 OBJ: Discuss the primary and secondary survey assessments during resuscitation and the acute phases of burn management. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. In patients with extensive burns, edema occurs in both burned and unburned areas because of: a. catecholamine-induced vasoconstriction. b . decreased glomerular filtration. c. increased capillary permeability. d . loss of integument barrier. ANS: 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). Catecholamineinduced vasoconstriction does not produce edema. Decreased glomerular filtration may cause fluid retention, but it is not responsible for the extensive edema seen after burn injury. Loss of integument barrier does not cause edema. DIF: Cognitive Level: Comprehension REF: p. 626 OBJ: Describe the pathophysiology of burns. TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 3. Tissue damage from burn injury activates an inflammatory response that increases the patients risk for: a. acute kidney injury. b . acute respiratory distress syndrome. c. infection. d . stress ulcers. ANS: 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. A systemic inflammatory response (SIRS) also increases the risk of acute kidney injury in the presence of poor tissue perfusion. Acute respiratory distress syndrome is also a potential complication, but the risk of infection is greater because of the loss of the skin barrier. Catecholamine release and gastrointestinal ischemia are the causes of stress ulcers. DIF: Cognitive Level: Comprehension REF: pp. 622-623 OBJ: Describe the pathophysiology of burns. TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 4. 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 ANS: C 154 pounds/2.2 = 70 kg 4 70 kg 50 = 14,000 mL, or 14 liters. DIF: Cognitive Level: Application REF: p. 636 | Box 20-1 OBJ: Formulate a plan of care for the patient with a burn injury. TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 5. The nurse is caring for a patient who has circumferential fullthickness burns of his forearm? A priority in the plan of care is : a. Keeping the extremity in a dependent position b . Active and passive range of motion every hour. c. Preparing for an escharotomy as a prophylactic measure d . Splinting the forearm ANS: 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. Peripheral pulses are assessed every hour, especially in circumferential burns of the extremities, to confirm adequate circulation. If signs and symptoms of compartment syndrome are present on serial examination, preparation is made for an escharotomy to relieve pressure and to restore circulation. DIF: Cognitive Level: Application REF: p. 638 OBJ: Formulate a plan of care for the patient with a burn injury. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. 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 nurses 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 not adhere well to burn wounds and a xenograft will be necessary to close the wound. ANS: C The autograft is the only permanent method of grafting and it uses the patients own tissue to cover the burn wound. Autografting is permanent and does not require a second surgery unless the graft fails. A biological or biosynthetic graft or dressing is a temporary wound covering. A xenograft is from an animal, usually pig skin and is a temporary graft. DIF: Cognitive Level: Application REF: p. 647 OBJ: Formulate a plan of care for the patient with a burn injury. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. 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. posttraumatic stress disorder. d . subacute delirium. ANS: 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. DIF: Cognitive Level: Application REF: p. 616 OBJ: Compare types of burns. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 8. 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. Central nervous system deficits b . Contractures c. Infection d . Stress ulcers ANS: A Lightning injury frequently causes cardiopulmonary arrest. However, of those patients who survive, 70% will have transient central nervous system deficits. Contractures, infection, and stress ulcer risks are no greater than with other causes of burn injury. DIF: Cognitive Level: Comprehension REF: p. 617 OBJ: Discuss the primary and secondary survey assessments during resuscitation and the acute phases of burn management. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 9. The nurse is providing care to manage the pain of a patient with burns. The physician has ordered opiates to be given intramuscularly. The nurse contacts the physician to change the order to intravenous administration because: a. intramuscular injections cause additional skin disruption. b . burn pain is so severe it requires relief by the fastest route available. c. hypermetabolism limits effectiveness of medications administered intramuscularly. d . tissue edema may interfere with drug absorption of injectable routes. ANS: D Edema and impaired circulation of the soft tissue interfere with absorption of medications administered subcutaneously or intramuscularly. Even though it is true intramuscular injections disrupt tissue, medication absorption is not effective. Burn pain is severe and intravenous administration is desired to relieve pain, but this is not the physiological basis for giving medications intravenously. Hypermetabolism affects medication effectiveness but is not the rationale for administering opioids intravenously. DIF: Cognitive Level: Comprehension REF: pp. 642-643 OBJ: Formulate a plan of care for the patient with a burn injury. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. 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. ANS: B In inhalation injury, the airway may become edematous quickly, making intubation difficult. Early intubation is recommended to protect the airway. Carbon monoxide poisoning may be present, but singed nose hairs are neither a symptom nor a reason for early intubation. Management of secretions is not an indication for intubation. Singed hairs and soot are more commonly symptoms of injury above the glottis rather than lower airway, below-the-glottis, signs and symptoms that will interfere with oxygenation and ventilation. DIF: Cognitive Level: Comprehension REF: p. 618 OBJ: Discuss the primary and secondary survey assessments during resuscitation and the acute phases of burn management. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 11. 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. acute kidney injury. b . acute respiratory distress syndrome. c. intraabdominal hypertension. d . disseminated intravascular coagulation disorder. ANS: C Intraabdominal 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. Acute kidney injury will not result from aggressive fluid resuscitation. Acute respiratory distress syndrome would present with signs of hypoxia and hypercarbia, but not a tense abdomen. Disseminated intravascular disorder may present as a tense abdomen if there is active bleeding, but it would not present with pulmonary symptoms. DIF: Cognitive Level: Application REF: p. 639 OBJ: Discuss the primary and secondary survey assessments during resuscitation and the acute phases of burn management. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 12. An elderly individual from an assisted living facility 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 patients burn injury. c. Immediately contact the police to report the suspected elder abuse. d . Ask the caregiver to describe exactly how the injury occurred. ANS: 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. While obtaining safety information on the temperature of the water heater is important, it is not a priority assessment question. The nurse should follow the hospital protocol for contacting appropriate authorities concerning suspected abuse, which may include contacting the police or social services. Asking the caregiver to describe how the injury occurred is important (e.g., there may be discrepancies in the physical assessment and reported mechanism of burn injury); however, examining the patient away from the caregiver is a priority. DIF: Cognitive Level: Application REF: p. 642 OBJ: Compare types of burn injuries. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. Silver is used as an ingredient in many burn dressings because it: a. stimulates tissue granulation. b . is effective against a wide spectrum of wound pathogens. c. provides topical pain relief. d . stimulates wound healing