Burns AQ Study Guide.
A patient is brought to the emergency department (ED) with a history of inhalation injury from hot air in a manufacturing unit. The patient has also sustained burns on the face, neck, and hands. What actions should the nurse perform immediately? Select all that apply.
Wait for laboratory reports. Observe for the next two hours. Perform early endotracheal intubation. Observe for signs of respiratory distress. Check for evidence of inhalation of smoke. - CORRECT ANSWER Perform early endotracheal intubation.
Observe for signs of respiratory distress.
Check for evidence of inhalation of smoke.
Checking for smoke inhalation is an important step to evaluate burn victims. Also, looking out for signs of respiratory distress like increased agitation, anxiety, restlessness, or a change in the rate or character of breathing is important. Early treatment includes airway management that involves early endotracheal
(preferably orotracheal) intubation, because it eliminates the need for an emergency tracheostomy. Observing the patient for the next two hours does not help because treatment must begin at the earliest
possible moment. In general, the patient suffering from burns on the face and neck may have mechanical obstruction caused by massive swelling of the tissues and requires intubation within one to two hours after the injury.
During the care of the patient with a burn in the acute phase, which new interventions should the nurse expect to do after the patient progresses from the emergent phase?
Monitor for signs of complications Assess and manage pain and anxiety Discuss possible reconstructive surgery Begin intravenous (IV) fluid replacement - CORRECT ANSWER Monitor for signs of complications
Monitoring for complications (e.g., wound infection, pneumonia, contractures) is needed in the acute phase. Fluid replacement occurs in the emergent phase. Assessing and managing pain and anxiety occurs in the emergent and the acute phases. Discussing possible reconstructive surgeries is done in the rehabilitation phase.
The patient in the acute phase of burn care has electrical burns on the left side of the body, type 2 diabetes mellitus, and a serum glucose level of 485 mg/dL. What should be the nurse's priority intervention to prevent a life-threatening complication of hyperglycemia for this burned patient?
Maintain a neutral pH Maintain fluid balance Replace the blood lost Replace serum potassium - CORRECT ANSWER Maintain fluid balance
This patient most likely is experiencing hyperosmolar hyperglycemic syndrome (HHS). HHS dehydrates a patient rapidly. Thus HHS combined with the massive fluid losses of a burn tremendously increases this patient's risk for hypovolemic shock and serious hypotension. This is clearly the nurse's priority , because
the nurse must keep up with the patient's fluid requirements to prevent circulatory collapse caused by low intravascular volume. There is no mention of blood loss. Fluid resuscitation will help to correct the pH and serum potassium abnormalities.
A patient who escaped from a burning building, which was enclosed with no ventilation, is brought to the emergency department. The patient is confused, has difficulty breathing, and has nasal burns. Which
condition does the nurse suspect? Pulmonary edema Lower airway injury Upper airway injury Carbon monoxide poisoning - CORRECT ANSWER Lower airway injury
A patient who was trapped in an enclosed burning building with no ventilation and is exhibiting confusion, dyspnea, and nasal burns is most likely experiencing a lower airway burn injury. Pulmonary edema may occur but not until 12 to 24 hours after the initial insult. Clinical manifestations of an upper airway injury include blisters, edema, difficulty in swallowing, and total airway obstruction. Carbon monoxide poisoning results in hypoxia, in which oxygen consumption is impaired.
Which fluid and electrolyte change occurs during the early emergent phase of burn injury?
Increased excretion of urine Increased colloidal osmotic pressure Return of interstitial fluid to the vascular space Movement of sodium and water into interstitial fluids - CORRECT ANSWER Movement of sodium and water into interstitial fluids
After the burn, in the emergent phase, the capillary walls become more permeable, causing the movement of sodium, water, and plasma proteins into the interstitial spaces and surrounding tissues. An
increased excretion of urine and the return of interstitial fluid to the vascular spaces occurs toward the end of the emergent phase. During the early emergent phase, colloidal osmotic pressure is decreased with progressive protein loss from the vascular spaces.
A patient who had a burn injury two days ago over 35% of the body is in the intensive care unit. The patient is intubated, on a mechanical ventilator, and fluid status is stable. Which of these interventions will the nurse anticipate for the patient's nutrition? Start total parenteral nutrition. Provide enteral tube feeding, starting at 20 mL/hour. Provide bolus enteral tube feedings four times a day. Feed at least 1500 calories/day in small, frequent meals. - CORRECT ANSWER Provide enteral tube feeding, starting at 20 mL/hour.
Nonintubated patients with a burn of less than 20% total body surface area (TBSA) will generally be able to eat enough to meet their nutritional needs. Intubated patients and those with larger burns require additional support. Enteral feedings (gastric or intestinal) have almost entirely replaced parenteral feeding. Early enteral feeding, usually with smaller-bore tubes, preserves gastrointestinal (GI) function, increases intestinal blood flow, and promotes optimal conditions for wound healing. In general, begin the feedings slowly at a rate of 20 to 40 mL/hr and increase to the goal rate within 24 to 48 hours.
A nurse is teaching a group of parents how to reduce the risk for injury related to burns. Which statement by a participant indicates effective learning?
"Frayed wires are OK to use at home." "I should hold regular home fire exit drills." "I should use gasoline with care to start a fire." "I should perform outdoor activities with caution during electrical storms." - CORRECT ANSWER "I should
hold regular home fire exit drills."
Regular home fire exit drills ensure the family knows the primary escape routes in case of any flame accidents at home. Frayed wires lack protective insulation, and contact may result in electrical injuries. Gasoline or kerosene should never be used to start a fire. Outdoor activities should be avoided during electrical storms.
When assessing a patient suffering from inhalation burns on the face and chest, what findings should a nurse anticipate? Select all that apply.
