Burns: Ch 53 In Critical Care Nursing: A Holistic Approach

Front 1

What is the best fluid to use for fluid resuscitation of a burn pt during the first 24 hrs?

A. Packed red blood cells
B. 5% dextrose in normal saline solution (D5NSS)
C. Albumin
D. Lactated Ringer's solution

Back 1

D. Lactated Ringer's solution

Lactated Ringer's solution is the best fluid to use for fluid resuscitation of a burn pt during the first 24hrs.

Front 2

A pt has been bured in a house fire. She sustained burns that damaged the epidermis, dermis, and subcutaneous tissue. Which one of the following classifications of burns best describes this pt's injuries?

A. first-degree
B. full thickness
C. superficial
D. partial-thickness

Back 2

B. full thickness

Burns damaging the epidermis, dermis, and subcutan

Front 3

Which of the following statements best describes the development of burn shock?

A. Increased capillary permeability causes an increase in vascular colloid osmotic pressure and a decrease in hydrostatic pressure.
B. Release of epinephrine produces increased heart rate, but it is ineffective, and cardiogenic shock occurs.
C. Increased capillary permeability results in decreased capillary colloid osmotic pressure.
D. The stress response (epinephrine and norepinephrine) causes selective vasoconstriction, resulting in shock.

Back 3

C. Increased capillary permeabiliry results in decreased capillary colloid osmotic pressure.

In burn shock, increased capillary permeability causes a loss of plasma fluid and proteins into the interstitial spaces, which results in decreased capillary colloid osmotic pressure.

Front 4

A pt complains of headache, nausea, and vertigo. What might these symptoms indicate?

A. smoke inhalation
B. carbon monoxide poisoning
C. cerebral edema
D. overhydration

Back 4

B. Carbon monoxide poisoning

Heachache, nausea, and vertigo are experienced with a carbon monoxide saturation of 20%. Prompt recognition of carbon monoxide injuries is essential for pt survival.

Front 5

A pt has sustained burns to his entire right arm and his anterior trunk. Using the "rules of nines" method, what is the percentage of his burn injury?

A. 48%
B. 27%
C. 18%
D. 9%

Back 5

B. 27%

A pt who has sustained burns to his entire right arm and his entire trunk has sustained injury to 27% of his body. The entire right arm counts for 9% and the anterior trunk counts for 18%, adding up to 27% total body surface area (TBSA).

Front 6

During the resuscitative phase, an elevated serum potassium level may occur. This is primarily the result of:

A. cellular injury
B. fluid volume loss
C. increased capillary permeability
D. interstitial edema

Back 6

A. cellular injury

During the resuscitative phase, the pt may have an elevated serum potassium level. Burn injuries result in tissue and cellular destruction. Cellular injuries result in a release of potssium into the intervascular space.

Front 7

Intramuscular injection of analgesics during the resuscitation phase is not recommended because:

A. narcotics can severely depress the respiratory system.
B. narcotics can further decrease the BP.
C. inadequate peripheral perfusion results in uneven absorption of the med.
D. tolerance to pain meds develop easily.

Back 7

C. inadequate peripheral perfusion results in uneven absorption of the med.

Intramuscular injection of analgesics during the resuscitative phase is not recommended because inadequate peripheral perfusion results in uneven reabsorption of the med.

Front 8

Which of the following nursing actions is appropriate when using silver sulfadiazine?

A. premedicate the pt for pain before application.
B. monitor acid-base balance
C. monitor WBCs
D. observe for signs of hepatotoxicity.

Back 8

C. monitor WBCs

When administering silver sulfadiazine, the nurse must monitor the pt's WBC count because an adverse effect of silver sulfadiazine is a transient leukopenia. After discontinuing the med, the leukopenia resolves without sequela. Silver sulfadiazine has a painless application and does not alter acid-base balance. In addition, it is not associated with hepatotoxicity.

Front 9

The edema in burn patients results from a rapid shift of plasma fluid from the:
A. extracellular to the intracellular level.
B. interstitial to the intravascular compartment.
C. intravascular into the interstitial compartments.
D. intracellular to the intravascular areas.

Back 9

C. intravascular into the interstitial compartments .

A rapid shift of plasma fluid from the intravascular compartment, across heat-damaged capillaries, into interstitial area, and to the burn wound itself, occurs.

Front 10

The loss of fluid throughout the body after a severe burn puts the patient at risk for:

A. thrombi.
B. coagulation problems.
C. disseminated intravascular coagulation (DIC).
D. All of the above are correct.

Back 10

D. All of the above are correct.

The loss of fluid results in a thickened, sluggish flow of the remaining circulatory volume. The antigen-antibody reaction adds to circulatory congestion by the clumping and agglutination of cells. Coagulation problems occur as a result of thromboplastin and the release of fibrinogen. If thrombi occur, they may cause ischemia. The increased coagulation process may develop into DIC.

Front 11

A burn that is dry, pale, and waxy is classified as a:
A. superficial partial-thickness burn.

B. full-thickness burn.
C. superficial burn.
D. deep partial-thickness burn.

Back 11

D. deep partial-thickness burn.

Deep partial-thickness burns involve the entire dermis, part of the dermis, and leave hair and sweat glands intact.

Front 12

Using the rule of nines, if an adult patient has each arm and hand burned, as well as his anterior trunk, the total body surface area (TBSA) burned is:

A. 30%.
B. 36%.
C. 18%.
D. 27%

Back 12

B. 36%

The rule of nines method counts each arm and hand as 9% and the anterior trunk as 18%.

Front 13

A normal laboratory finding following a burn injury is:

A. decreased leukocytes.
B. decreased blood urea nitrogen (BUN) level.
C. increased hematocrit.
D. decreased potassium

Back 13

C. increased hematocrit

The leak from the vascular department, which consists of sodium, water, and plasma proteins, is followed by a decrease in cardiac output, hemoconcentration of red blood cells, diminished perfusion to major organs, and generalized body edema.

Front 14

The best single indicator of fluid resuscitation in patients following a severe burn injury is:

A. body weight.
B. urine output.
C. skin turgor.
D. hematocrit levels

Back 14

B. urine output

Urine output is the single best indicator of fluid resuscitation.

Front 15

The purpose of an escharotomy is to:

A. allow proper healing of the wound.
B. restore adequate tissue perfusion.
C. provide more mobilization in the burned area.
D. promote quicker healing time

Back 15

B. restore adequate tissue perfusion

Any circumferential burn to an arm or leg may mimic compartment syndrome. Edema formation produces significant vascular compromise in the affected limb.

Front 16

Burn shock, a form of hypovolemic shock, is largely a process of:

A. fluid shifts from the burn area into the vascular space.
B. fluid loss at the burn site.
C. fluid shifts from the vascular space into the interstitial areas of the burn wound.
D. extensive bleeding secondary to debridement.

Back 16

C. fluid shifts from the vascular space into the interstitial areas of the burn wound.

Within minutes of thermal injury, a marked increase in capillary hydrostatic pressure occurs in the injured tissue, accompanied by an increase in capillary permeability. A rapid shift of plasma fluid from the intravascular compartment, across heat-damaged capillaries, into interstitial area, and to the burn wound itself, occurs.

Front 17

Signs of a potential inhalation injury include:

A. singed nasal hairs.
B. coughing up soot.
C. hoarse voice.
D. All of the above are correct.

Back 17

D. All of the above are correct

Singed nasal hairs, burns of oral or pharyngeal mucous membranes and/or in the perioral area of the neck, soot in sputum, and change in voice are all suggestive of an inhalation injury.

Front 18

Treatment for a suspected inhalation injury will include:

A. immediate endotracheal intubation.
B. immediate tracheostomy.
C. administration of humidified oxygen.
D. bronchoscopy and debridement of burned tissue.

Back 18

C. administration of humidified oxygen

Humidified oxygen is administered to prevent drying and sloughing of the mucosa.

Front 19

T.J. weighs 65 kg and has 35% TBSA burned. Using the Baxter (Parkland) formula, the amount of fluid necessary in the first eight hours would be:

A. 4,550 mL.
B. 9,100 mL.
C. 6,350 mL.
D. 2,150 mL

Back 19

A. 4,550 mL.

The Baxter (Parkland) formula requires 4 mL of lactated Ringer's solution per kilogram of body weight per percentage. 65 kg X 4 mL X 35% = 9,100 mL. The amount infused in the first 8 hours is 1/2 this amount.

Front 20

The fluid of choice for initial fluid replacement is:

A. plasma.
B. 0.9 normal saline.
C. D5 ½ NS.
D. lactated Ringer's solution.

Back 20

D. lactated Ringer's solution.

Lactated Ringer's solution is used as the crystalloid solution because it is a balanced salt solution.

Front 21

Angie, a 19-year-old college student, has a 60% TBSA second- and third-degree burn. While monitoring intake and output, the nurse notes dark brown urine. This is probably the result of:

A. administer an analgesic 20 to 30 minutes before procedure.
B. administer antibiotics 20 to 30 minutes before procedure.
C. complete ROM exercises.
D. ambulate the patient.

Back 21

A. administer an analgesic 20 to 30 minutes before procedure.

Because baths are usually painful, patients should receive an analgesic 20 to 30 minutes before the bath.

Front 22

The primary topical agent of choice used on admission for a burn injury is:

A. nystatin.
B. silver sulfadiazine.
C. povidone-iodine.
D. entamycin

Back 22

B. silver sulfadiazine.

Silver sulfadiazine is the primary topical agent of choice used on admission.

Front 23

A 62-year-old patient with atrial fibrillation is being treated with warfarin. The nurse notices small, red, lesion-like freckles on the patient's arms. These are noted as:

A. ecchymoses.
B. angiomas.
C. urticaria.
D. petechiae

Back 23

D. petechiae.

Petechiae are purple or red, small lesions which are easily seen on light-skinned individuals.

Front 24

A whitish coating on the tongue caused by Candida is:

A. nevus flammeus.
B. hairy tongue.
C. thrush.
D. telangiectasis

Back 24

C. thrush.

Oral candidiasis, also known as thrush, manifests as a whitish coating of the oral mucosa, especially the tongue.

Front 25

Gregory is a 46-year-old African-American male who is admitted to the ICU with abdominal hemorrhage following a MVA. His skin color is yellowish-brown. The nurse notes this as:

A. jaundice.
B. pallor.
C. cyanosis.
D. erythema.

Back 25

B. pallor.

Pallor in dark-skinned people is seen as yellowish-brown or ashen color.

Front 26

The nurse documents that the angle of the patient's nail is over 180 degrees. This is called:

A. clubbing.
B. koilonychias.
C. onychomycosis.
D. hypertrophy.

Back 26

A. clubbing.

When the angle of the nail is 180 degree or greater, clubbing is said to be present.

Front 27

The nurse is able to indent the skin on the dorsal surface of the foot 4 mm while palpating pedal pulses. The nurse documents this assessment as:

A. nonpitting edema.
B. 2+ pitting edema.
C. 3+ pitting edema.
D. 4+ pitting edema.

Back 27

B. 2+ pitting edema.

2+ pitting edema is identified as edema that retains a 4-mm depression when palpated.

Front 28

Angie, a 19-year-old college student, has a 60% TBSA second- and third-degree burn. While monitoring intake and output, the nurse notes dark brown urine. This is probably the result of:

A. hemoconcentration.
B. myoglobin.
C. melanin.
D. alkalosis

Back 28

B. myoglobin

Renal dysfunction may be the result of inadequate fluid resuscitation or it may be the consequence of the liberation of the myoglobin and hemoglobin from damaged cells.

Front 29

A patient with impaired wound healing should have a diet high in:

A. protein.
B. carbohydrates.
C. fats
D. sodium.

Back 29

A. protein.

Protein is a basic and key component of all cellular activity. Without proteins, the inflammatory process is impaired and the risk of infection increases. Protein is a key component in the healing process.

Front 30

Mrs. Foley has a pressure ulcer on her coccyx that is 5 cm in diameter and appears as a shallow open wound that is pink in color. This a:

A. Stage I ulcer.
B. Stage II ulcer.
C. Stage III ulcer.
D. Stage IV ulcer

Back 30

B. Stage II ulcer.

A Stage II ulcer involves partial-thickness tissue loss and presents as a blistered or denuded area, a shallow open wound.

Front 31

The nurse identifies a tunnel in a wound that previously contained a drain. She can document the length of the tunnel by inserting a:

A. cotton swab.
B. ruler.
C. measuring tape.
D. None of the above is correct.

Back 31

A. cotton swab.

To assess a tunnel, use a sterile cotton swab.

Front 32

Vacuum-assisted wound closure promotes healing by which process?

A. Stimulation of granulization
B. Infection is diminished
C. A moist environment
D. All of the above are correct.

Back 32

D. All of the above are correct.

With the VAC system, granulation tissue is stimulated, infection and bacterial colonization are decreased, and wound closure occurs in a moist “vacuum” environment.

Front 33

Valerie has a wound closed using a wound adhesive. The nurse should not:

A. cover the wound with a sterile dressing.
B. inspect the wound.
C. clean with betadine solution.
D. rinse with saline.

Back 33

C. clean with betadine solution.

Incisions in which wound adhesives are used are not cleansed or soaked with any wound cleaner, although they may be gently rinsed.