Lewis - Chapter 24: Burns Exam Study Guide Test.
When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes dry, pale, and hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth?
a. First-degree skin dest...
Lewis - Chapter 24: Burns Exam Study Guide Test.
When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes dry, pale, and hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth?
a. First-degree skin destruction
b. Full-thickness skin destruction
c. Deep partial-thickness skin destruction
d. Superficial partial-thickness skin destruction - CORRECT ANSWER ANS: B
With full-thickness skin destruction, the appearance is pale and dry or leathery, and the area is painless because of the associated nerve destruction. Erythema, swelling, and blisters point to a deep partial-
thickness burn. With superficial partial-thickness burns, the area is red, but no blisters are present. First-
degree burns exhibit erythema, blanching, and pain.
DIF: Cognitive Level: Understand (comprehension)
On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which of the following prescribed actions should be the nurse's priority?
a. Monitoring urine output every 4 hours.
b. Continuing to monitor the laboratory results.
c. Increasing the rate of the ordered IV solution.
d. Typing and crossmatching for a blood transfusion. - CORRECT ANSWER ANS: C
The patient's laboratory results show hemoconcentration, which may lead to a decrease in blood flow to
the microcirculation unless fluid intake is increased. Because the hematocrit and hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase once the patient's fluid balance has been restored. On admission to a burn unit, the urine output would be monitored more often than every 4 hours (likely every1 hour).
DIF: Cognitive Level: Analyze (analysis A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take?
a. Encourage the patient to cough and auscultate the lungs again.
b. Notify the health care provider and prepare for endotracheal intubation.
c. Document the results and continue to monitor the patient's respiratory rate.
d. Reposition the patient in high-Fowler's position and reassess breath sounds. - CORRECT ANSWER ANS:
B
The patient's history and clinical manifestations suggest airway edema, and the health care provider should be notified immediately so that intubation can be done rapidly. Placing the patient in a more upright position or having the patient cough will not address the problem of airway edema. Continuing to monitor is inappropriate because immediate action should occur.
DIF: Cognitive Level: Apply (application)
A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be administered in the first 24 hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids?
a. 219 mL/hr c. 938 mL/hr
b. 625 mL/hr d. 1875 mL/hr - CORRECT ANSWER ANS: C
Half of the fluid replacement using the Parkland formula is administered in the first 8 hours and the other half over the next 16 hours. In this case, the patient should receive half of the initial rate, or 938 mL/hr.
DIF: Cognitive Level: Apply (application)
During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion?
a. Check skin turgor. c. Assess mucous membranes.
b. Monitor daily weight. d. Measure hourly urine output. - CORRECT ANSWER ANS: D
When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hr. The patient's weight is
not useful in this situation because of the effects of third spacing and evaporative fluid loss. Mucous membrane assessment and skin turgor also may be used, but they are not as adequate in determining that fluid infusions are maintaining adequate perfusion.
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