When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the skin is
dry, pale, hard skin. The patient states that the burn is not painful. What term would the nurse use to
document the burn depth?
full thickness skin destruction
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Burns Nursing
When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the skin is
dry, pale, hard skin. The patient states that the burn is not painful. What term would the nurse use to
document the burn depth?
full thickness skin destruction
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with full thickness skin destruction the appearance is what?
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.
superficial partial thickness burns the appearance is what?
red, but no blisters are present. First-degree burns exhibit erythema, blanching, and pain.
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, serum K+ 4.9 mEq/L, and serum
Na+ 135 mEq/L. Which action will the nurse anticipate taking now?
Increase the rate of the ordered IV solution. The patient's laboratory data 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.
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?
,Notify the health care provider and prepare for endotracheal intubation. 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.
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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?
938 mL/hour
Parkland fluid replacement formula; the first 8 hours you administer how much fluid?
Half of the fluid
Parkland fluid replacement formula: the remaining 16 hours how much fluid is administered?
half the fluid
During the emergent phase of burn care, which assessment will be most useful in determining whether
the patient is receiving adequate fluid infusion?
Measure hourly urine output.
A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain
adequate nutrition, the nurse should plan to take which action?
Insert a feeding tube and initiate enteral feedings.
, While the patient’s full–thickness burn wounds to the face are exposed, what is the best nursing action
to prevent cross contamination?
Wear gowns, caps, masks, and gloves during all care of the patient.
A nurse is caring for a patient who has burns of the ears, head, neck, and right arm and hand. The nurse
should place the patient in which position?
Elevate the right arm and hand on pillows and extend the fingers. The right hand and arm should be
elevated to reduce swelling and the fingers extended to avoid flexion contractures (even though this
position may not be comfortable for the patient). The patient with burns of the ears should not use a
pillow for the head because this will put pressure on the ears, and the pillow may stick to the ears.
Patients with neck burns should not use a pillow because the head should be maintained in an extended
position in order to avoid contractures.
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A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength
and numbness in the toes. Which action should the nurse take?
Notify the health care provider. The decrease in pulse in a patient with circumferential burns indicates
decreased circulation to the legs and the need for an escharotomy.
Esomeprazole (Nexium) is prescribed for a patient who incurred extensive burn injuries 5 days ago.
Which nursing assessment would best evaluate the effectiveness of the medication?
Stools for occult blood. H2 blockers and proton pump inhibitors are given to prevent Curling's ulcer in
the patient who has suffered burn injuries. Proton pump inhibitors usually do not affect bowel sounds,
stool frequency, or appetite.
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