c.↓ Hct, ↑ serum albumin, ↑ serum Na, ↑ serum K.
d.↑ Hct, ↑ serum albumin, ↓ serum Na, ↓ serum K.
8. What is the initial cause of hypovolemia during the emergent phase of burn injury?
a. Increased capillary permeability b. Loss of sodium to the interstitium c. Decreased vascular oncotic pressure d. Fluid loss from denuded skin surfaces
9. How is the immune system altered in a burn injury?
a. Bone marrow stimulation
b. Increase in immunoglobulin levels
c. Impaired function of white blood cells (WBCs)
d. Overwhelmed by microorganisms entering denuded tissue
10. What is one clinical manifestation the nurse would expect to find during the emergent phase in a patient with a full-thickness burn over the lower half of the body?
a. Fever b. Shivering c. Severe pain d. Unconsciousness
11. Priority Decision: A patient has a 20% TBSA deep partial-thickness and full-thickness burn to the right anterior chest and entire right arm. What is most important for a nurse to assess in this patient?
a. Presence of pain b. Swelling of the arm c. Formation of eschar
d. Presence of pulses in the arms
12. Which burn patient should have orotracheal or endotracheal intubation?
a. Carbon monoxide poisoning
b. Electrical burns causing cardiac dysrhythmias c. Thermal burn injuries to the face, neck, or airway
d. Respiratory distress from eschar formation around the chest
13. A patient is admitted to the emergency department at 10:15 PM following a flame burn at 9:30 PM. The patient has 40% TBSA deep partial-thickness and full-thickness burns and weighs 132 lb.
a. According to the Parkland (Baxter) formula, the type of fluid prescribed for the patient would be ____________________, and the total amount to be administered during the first 24 hours would be ______ mL.
b. The schedule for the fluid administration would be ________mL between ___________ and ___________ (time), ________mL between ___________ and ___________, and ______ mL between __________ and __________.
c. Colloidal solutions are given in the second 24 hours. Based on the patient's body weight, what amount of these solutions will be given during this time?
d. The adequacy of the patient's fluid replacement is determined by____________________ and ____________________.
14. A patient's deep partial-thickness facial burns are treated with the open method. What should the nurse do when caring for the patient?
a. Ensure that sterile water is used in the debridement tank.
b. Wear a cap, mask, gown, and gloves during patient contact.
c. Use sterile gloves to remove the dressings and wash the wounds.
d. Apply topical antimicrobial ointment with clean gloves to prevent wound trauma.
15. A patient with deep partial-thickness burns over 45% of his trunk and legs is going for debridement in the cart shower 48 hours post-burn. What is the drug of choice to control the patient's pain during this activity?
a. IV morphine b. Midazolam
c. IM meperidine (Demerol) d. Long-acting oral morphine
16. The nurse assesses that bowel sounds are absent and abdominal distention is present in a patient 12 hours post-burn. The nurse notifies the health care provider and anticipates doing what action next?
a. Withhold all oral intake except water.
b. Insert a nasogastric tube for decompression.
c. Administer a H2-histamine blocker such as ranitidine (Zantac).
d. Administer nutritional supplements through a feeding tube placed in the duodenum.
17. How should the nurse position the patient with ear, face, and neck burns?
a. Prone b. On the side c. Without pillows
d. With extra padding around the head
18. Identify the factors that increase nutritional needs of the patient during the emergent and acute phases of burn injury (select all that apply).
a. Electrolyte imbalance b. Core temperature elevation
c. Calories and protein used for tissue repair
d. Hypometabolic state secondary to decreased gastrointestinal function
e. Massive catabolism characterized by protein breakdown and increased gluconeogenesis
19. At the end of the emergent phase and the initial acute phase of burn injury, a patient has a serum sodium level of 152 mEq/L (152 mmol/L) and a serum potassium level of 2.8 mEq/L (2.8 mmol/L).
What could have caused these imbalances?
a. Free oral water intake b. Prolonged hydrotherapy
c. Mobilization of fluid and electrolytes in the acute phase
d. Excessive fluid replacement with dextrose in water without potassium supplementation 20. Priority Decision: A burn patient has a nursing diagnosis of impaired physical mobility related
to a limited range of motion (ROM) resulting from pain. What is the best nursing intervention for this patient?
a. Have the patient perform ROM exercises when pain is not present.
b. Provide analgesic medications before physical activity and exercise.
c. Teach the patient the importance of exercise to prevent contractures.
d. Arrange for the physical therapist to encourage exercise during hydrotherapy.
21. The nurse initially suspects the possibility of sepsis in the burn patient based on which change?
a. Vital signs b. Urinary output
c. Gastrointestinal function d. Burn wound appearance
22. Identify one major complication of burns that is believed to be stress related that may occur in each of the following systems during the acute burn phase.
Neurologic Gastrointestinal Endocrine
23. Complete the following sentences.
a. A permanent skin graft that may be available for the patient with large body surface area burns who has limited skin for donor harvesting is ______________________.
b. Early excision and grafting of burn wounds involve excising ____________________ down to clean viable tissue and applying a(n) ____________________ whenever possible.
c. Blebs can be removed from facial skin grafts by ____________________.
24. The burn patient has developed an increasing dread of painful dressing changes. What would be the most appropriate treatment to ask the health care provider to prescribe?
a. Midazolam to be used with morphine before dressing changes
b. Morphine in a dosage range so that more may be given before dressing changes c. Buprenorphine (Buprenex) to be administered with morphine before dressing changes d. Patient-controlled analgesia so that the patient may have control of analgesic administration 25. During the rehabilitation phase of a burn injury, what can control the contour of the scarring?
a. Pressure garments b. Avoidance of sunlight c. Splinting joints in extension d. Application of emollient lotions
26. A 24-yr-old female patient does not want the wound cleansing and dressing change to take place. She asks, “What difference will it make anyway?” What will the nurse encourage the patient to do?
a. Have the wound cleaned and the dressing changed.
b. Have a snack before having the treatments completed.
c. Talk about what is troubling her with the nurse and/or her family.
d. Call the chaplain to come and talk to her and convince her to have the care.
27. Priority Decision: The nurse has received the change-of-shift report on his group of patients.
Indicate the priority order in which the nurse should see these patients.
_____ a. A 40-yr-old female who is returning from the postanesthesia care unit (PACU) following surgical debridement of her back and legs
_____ b. A 76-yr-old male with partial-thickness burns of his arms and abdomen who is complaining of severe pain
_____ c. A 62-yr-old female who was just admitted following partial-thickness burns to her anterior chest, face, and neck
_____ d. An 18-yr-old male with full-thickness burns of his lower extremities who is refusing to go for his scheduled dressing change
Case Study
Burn Patient in Rehabilitation Phase
(©vystek-photographie/iStock/Thinkstock)
Patient Profile
D.K. is a 30-yr-old woman who has been in the burn center for 3 weeks. She sustained partial- and full-thickness burns to both hands and forearms while cooking. She has undergone three surgeries for escharotomy and split-thickness skin grafting. She is married and has three young children at home. Her husband assists her with all activities when he is present. Her health care providers feel she is nearly ready for discharge, but she has been tearful and noncompliant with therapy. D.K.
and her husband refuse to look at her hand grafts, which continue to require light dressings. She has not seen her children since admission.
Discussion Questions
Using a separate sheet of paper, answer the following questions:
1. When should discharge planning be initiated with D.K.? Who should be involved in the planning and implementation of the teaching process before discharge?
2. Teamwork and Collaboration: Describe the nutritional needs that D.K. will have after discharge and interventions to meet those needs.
3. Patient-Centered Care: D.K. has been wearing hand and elbow splints at night while in the burn center. What instructions will D.K. need regarding her splinting and exercise routine at home?
4. Patient-Centered Care: D.K. complains of tightness in her hands, which restricts her motion.
She uses this excuse to avoid exercise and independent performance of her activities of daily living. What activities and teaching would be beneficial to address this issue?
5. Teamwork and Collaboration: D.K. and her husband have been extremely upset and anxious regarding D.K.'s discharge. They are not actively participating in the discharge planning process. What priority interventions should the interprofessional team implement to assist the couple?
6. What are some of the feelings D.K. and her family may experience following her return home?
What can the nurse do to prepare the family?
7. Patient-Centered Care: What are the priority needs that must be addressed with D.K. and her husband regarding dressing changes and graft care before discharge from the burn center?
Discuss how this should be managed.
8. Priority Decision: Based on the assessment data presented, what are the priority nursing diagnoses? Are there any collaborative problems?
S E C T I O N 5
Problems of Oxygenation: Ventilation
OUTLINE
25 Assessment of Respiratory System 26 Upper Respiratory Problems 27 Lower Respiratory Problems 28 Obstructive Pulmonary Diseases