Chapter 21: Burns
Sole: Introduction to Critical Care Nursing, 8th Edition
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MULTIPLE CHOICE
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1. What is the optimal measurement of intravascular fluid status during the immediate fluid
resuscitation phase of burn treatment?
a. Blood urea nitrogen
b. Daily weight
c. Hourly intake and urine output
d. Serum potassium
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ANS: C
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During initial fluid resuscitation, urine output helps guide fluid resuscitation needs. Measuring
hourly intake and output is most effective in determining the needs for additional fluid
infusion than is urine output alone. Blood urea nitrogen may be used to monitor volume
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status, but it is affected by the hypermetabolic state seen after burns, so it is not the optimal
measure of intravascular fluid status. Daily weight measures overall volume status, not just
intravascular volume. Serum potassium is released with tissue damage and thus is not the
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optimum measure of intravascular fluid status.
DIF: Cognitive Level: Comprehension
OBJ: Discuss the primary and secondary survey assessments during resuscitation and the acute
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phases of burn management.
TOP: Nursing Process
Step: Assessment
MSC: NCLEX: Physiological Integrity
2. In patients with extensive burns, what process is responsible for edema occurring in both
burned and unburned areas?
a. Catecholamine-induced vasoconstriction
b. Decreased glomerular filtration
c. Increased capillary permeability
d. Loss of integument barrier
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ANS: C
Capillary permeability is altered in burns beyond the area abirb.com/test
of tissue damage, resulting in
significant shift of proteins, fluid, and electrolytes resulting in edema (third spacing).
Catecholamine-induced vasoconstriction does not produce edema. Decreased glomerular
filtration may cause fluid retention, but it is not responsible
for the extensive edema seen after
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burn injury. Loss of integument barrier does not cause edema.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process Step: Evaluation
OBJ: Describe the pathophysiology of burns.
MSC: NCLEX: Physiological
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3. Tissue damage from burn injury activates an inflammatory response that increases the
patient’s risk for what complication?
a. Acute kidney injury
b. Acute respiratory distress syndrome
c. Infection
d. Stress ulcers
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ANS: C
The loss of skin as the primary barrier against microorganisms and activation of the
inflammatory response cascades results in immunosuppression,
placing the patient at an
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increased risk of infection. A systemic inflammatory response (SIRS) also increases the risk
of acute kidney injury in the presence of poor tissue perfusion. Acute respiratory distress
syndrome is also a potential complication, but the risk of infection is greater because of the
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loss of the skin barrier. Catecholamine release and gastrointestinal ischemia are the causes of
stress ulcers.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process Step: Evaluation
OBJ: Describe theabirb.com/test
pathophysiology of burns.
MSC: NCLEX: Physiological Integrity
4. A patient who weighs 154 pounds has a burn injury that covers 50% of body surface area. The
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nurse calculates the intravenous (IV) fluid needs for the first
24 hours after a burn injury using
a standard fluid resuscitation formula. The nurse plans to administer what amount of fluid in
the first 24 hours?
a. 2800 mL
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b. 7000 mL
c. 14 L
d. 28 L
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ANS: C
154 pounds/2.2 = 70 kg
4 u 70 kg u 50 = 14,000 mL, or 14 liters.
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DIF: Cognitive Level: Analysis
OBJ: Formulate a plan of care for the patient with a burn injury.
TOP: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
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5. The nurse is caring for a patient who has circumferential full-thickness burns of his forearm?
What is the priority intervention in the plan of care?
a. Keeping the extremity in a dependent position
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b. Active and passive range of motion every hour
c. Preparing for an escharotomy as a prophylactic measure
d. Splinting the forearm
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ANS: B
Special attention is given to circumferential (completely surrounding a body part) full
thickness burns of the extremities. Pressure from bands of eschar or from edema that develops
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as resuscitation proceeds may impair blood flow to underlying and distal tissue. Therefore,
extremities are elevated to reduce edema. Active or passive range-of-motion (ROM) exercises
are performed every hour for 5 minutes to increase venous return and to minimize edema.
Peripheral pulses are assessed every hour, especially in circumferential
burns of the
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extremities, to confirm adequate circulation. If signs and symptoms of compartment syndrome
are present on serial examination, preparation is made for an escharotomy to relieve pressure
and to restore circulation.
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DIF:
OBJ:
TOP:
MSC:
Cognitive Level: Application
Formulate a plan of care for the patient with a burn injury.
Nursing Process Step: Implementation
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NCLEX: Physiological Integrity
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WWW.THENURSINGMASTERY.COM
6. The patient asks the nurse if the placement of the autograft over a full-thickness burn will be
the only surgical intervention needed to close the wound. What
is the nurse’s best response?
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a. “Unfortunately, an autograft skin is a temporary graft and a second surgery will be
needed to close the wound.”
b. “An autograft is a biological dressing that will eventually be replaced by your body
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generating new tissue.”
c. “Yes, an autograft will transfer your own skin from one area of your body to cover
the burn wound.”
d. “Unfortunately, autografts frequently do not adhere well
to burn wounds and a
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xenograft will be necessary to close the wound.”
ANS: C
The autograft is the only permanent method of grafting and
it uses the patient’s own tissue to
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cover the burn wound. Autografting is permanent and does not require a second surgery
unless the graft fails. A biological or biosynthetic graft or dressing is a temporary wound
covering. A xenograft is from an animal, usually pig skin and is a temporary graft.
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DIF:
OBJ:
TOP:
MSC:
Cognitive Level: Application
Formulate a plan of care for the patient with a burn injury.
Nursing Process Step: Implementation
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NCLEX: Physiological Integrity
7. A patient admitted with severe burns to the face and hands is showing signs of extreme
agitation. The nurse should explore the mechanism of burnabirb.com/test
injury possibly related to what
data noted in the patient’s medical history?
a. Excessive alcohol use
b. Methamphetamine use
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c. Posttraumatic stress disorder
d. Subacute delirium
ANS: B
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A vague or inconsistent injury history, burns to the face and hands, and signs of agitation or
substance withdrawal should alert the nurse to a potential methamphetamine-related injury.
DIF: Cognitive Level: Application
TOP: Nursing Process Step: Assessment
OBJ: Compare types
of burns.
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MSC: NCLEX: Physiological Integrity
8. The nurse is caring for patient who has been struck by lightning. Because of the nature of the
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injury, the nurse assesses the patient for which possible complication?
a. Central nervous system deficits
b. Contractures
c. Infection
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d. Stress ulcers
ANS: A
Lightning injury frequently causes cardiopulmonary arrest.abirb.com/test
However, of those patients who
survive, 70% will have transient central nervous system deficits. Contractures, infection, and
stress ulcer risks are no greater than with other causes of burn injury.
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DIF: Cognitive Level: Comprehension
OBJ: Discuss the primary and secondary survey assessments during resuscitation and the acute
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WWW.THENURSINGMASTERY.COM
phases of burn management.
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process Step: Assessment
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9. The nurse is providing care to a patient with burns whose care of plan care includes a
prescription for opiates to be given intramuscularly for pain. Why would the nurse contact the
primary care provider (PCP) to change the order to intravenous administration?
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a. Intramuscular injections cause additional skin disruption.
b. Burn pain is so severe it requires relief by the fastest route available.
c. Hypermetabolism limits effectiveness of medications administered
intramuscularly.
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d. Tissue edema may interfere with drug absorption of injectable routes.
ANS: D
Edema and impaired circulation of the soft tissue interfereabirb.com/test
with absorption of medications
administered subcutaneously or intramuscularly. Even though it is true intramuscular
injections disrupt tissue, medication absorption is not effective. Burn pain is severe and
intravenous administration is desired to relieve pain, but this is not the physiological basis for
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giving medications intravenously. Hypermetabolism affects
medication effectiveness but is
not the rationale for administering opioids intravenously.
DIF:
OBJ:
TOP:
MSC:
Cognitive Level: Comprehension
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Formulate a plan of care for the patient with a burn injury.
Nursing Process Step: Implementation
NCLEX: Physiological Integrity
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10. When paramedics report singed hairs in the nose of a burn patient, it is recommended that the
patient be intubated. What is the reasoning for the immediate intubation?
a. Carbon monoxide poisoning always occurs when soot is visible.
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b. Inhalation injury above the glottis may cause significant
edema that obstructs the
airway.
c. The patient will have a copious amount of mucus that will need to be suctioned.
d. The singed hairs and soot in the nostrils will cause dysfunction
of cilia in the
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airways.
ANS: B
In inhalation injury, the airway may become edematous quickly,
making intubation difficult.
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Early intubation is recommended to protect the airway. Carbon monoxide poisoning may be
present, but singed nose hairs are neither a symptom nor a reason for early intubation.
Management of secretions is not an indication for intubation. Singed hairs and soot are more
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commonly symptoms of injury above the glottis rather than lower airway, below-the-glottis,
signs and symptoms that will interfere with oxygenation and ventilation.
DIF: Cognitive Level: Comprehension
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OBJ: Discuss the primary and secondary survey assessments during resuscitation and the acute
phases of burn management.
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
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11. A patient with a 60% burn in the acute phase of treatment develops a tense abdomen,
decreasing urine output, hypercapnia, and hypoxemia. Based on this assessment, the nurse
anticipates interventions to evaluate and treat the patient for what complication?
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a. Acute kidney injury
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b. Acute respiratory distress syndrome
c. Intraabdominal hypertension
d. Disseminated intravascular coagulation disorder
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ANS: C
Intraabdominal hypertension (IAH) is a serious complication caused by circumferential torso
burn injuries or edema from aggressive fluid resuscitation.abirb.com/test
Signs and symptoms of IAH
include tense abdomen, decreased urine output, and worsening pulmonary function. Acute
kidney injury will not result from aggressive fluid resuscitation. Acute respiratory distress
syndrome would present with signs of hypoxia and hypercarbia, but not a tense abdomen.
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Disseminated intravascular disorder may present as a tense abdomen if there is active
bleeding, but it would not present with pulmonary symptoms.
DIF: Cognitive Level: Comprehension
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OBJ: Discuss the primary and secondary survey assessments during resuscitation and the acute
phases of burn management.
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
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12. An elderly individual from an assisted living facility (ALF) presents with severe scald burns
to the buttocks and back of the thighs. The caregiver from the ALF accompanies the patient to
the emergency department and states that the bath water was
“too hot” and that the “patient sat
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in the water too long.” What should the nurse do to best achieve an accurate history of the
event?
a. Ask the caregiver at what temperature the water heater is set in the home.
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b. Ask the caregiver to step out while examining the patient’s
burn injury.
c. Immediately contact the police to report the suspected elder abuse.
d. Ask the caregiver to describe exactly how the injury occurred.
ANS: B
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In cases of suspected abuse, especially in vulnerable patients such as children, elderly, and
mentally impaired, it is important to assess the injured patient separately from the caregiver.
While obtaining safety information on the temperature of the
water heater is important, it is
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not a priority assessment question. The nurse should follow the hospital protocol for
contacting appropriate authorities concerning suspected abuse, which may include contacting
the police or social services. Asking the caregiver to describe how the injury occurred is
important (e.g., there may be discrepancies in the physicalabirb.com/test
assessment and reported
mechanism of burn injury); however, examining the patient away from the caregiver is a
priority.
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DIF: Cognitive Level: Application
OBJ: Compare types of burn injuries.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
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13. Why is silver is used as an ingredient in many burn dressings?
a. Stimulates tissue granulation.
b. Is effective against a wide spectrum of wound pathogens.
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c. Provides topical pain relief.
d. Stimulates wound healing.
ANS: B
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Silver is an ingredient in many dressings because it helps prevent infection against a wide
spectrum of common pathogens. Silver does not stimulate tissue granulation; nor does it
provide pain relief or stimulate wound healing processes. abirb.com/test
DIF:
OBJ:
TOP:
MSC:
Cognitive Level: Comprehension
Formulate a plan of care for the patient with a burn injury.
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Nursing Process Step: Implementation
NCLEX: Physiological Integrity
14. The nurse understands that negative-pressure wound therapy may be used in the treatment of
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partial-thickness burn wounds to accomplish what outcome?
a. Maintain a closed wound system to decrease the risk of infection.
b. Remove excessive wound fluid and promote moist wound healing.
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c. Increase patient mobility with large burn wounds.
d. Quantify wound drainage amount for more accurate output assessment.
ANS: B
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Negative-pressure wound therapy can be used to treat grafts
or partial-thickness burns by
decompressing edematous interstitial spaces that enhance local perfusion, optimizing wound
healing. This therapy also provides a moist wound-healing environment. The system is closed
and may reduce the risk of infection but may not prevent infection.
Patients are less mobile
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because the system needs an electrical source to function. Wound drainage is quantified by
using the negative-pressure wound therapy system, but this is not a primary indication for the
therapy.
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DIF:
OBJ:
TOP:
MSC:
Cognitive Level: Comprehension
Formulate a plan of care for the patient with a burn injury.
Nursing Process Step: Implementation
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NCLEX: Physiological Integrity
15. The nurse caring for a patient with an electrical injury understands that patients with electrical
injury are at a high risk for acute kidney injury secondary abirb.com/test
to what related process?
a. Hypervolemia from burn resuscitation
b. Increased incidence of ureteral stones
c. Nephrotoxic antibiotics for prevention of infection
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d. Release of myoglobin from injured tissues
ANS: D
Myoglobin is released during electrical injury and is a risk factor for rhabdomyolysis and
acute kidney injury. Hypervolemia is not a cause of acute abirb.com/test
kidney injury. Ureteral stones and
nephrotoxic antibiotics may cause acute kidney injury but is not associated with the electrical
injury.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process Step: Evaluation
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OBJ: Describe the pathophysiology of burns.
MSC: NCLEX: Physiological Integrity
16. What is the priority nursing intervention for a patient whoabirb.com/test
experienced a chemical burn
injury?
a. Remove the patient’s clothes and flush the area with water.
b. Apply saline compresses.
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c. Contact a poison control center for directions on neutralizing
agents.
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WWW.THENURSINGMASTERY.COM
d. Remove all jewelry.
ANS: A
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As long as the chemical remains in contact with the skin, burn damage will result. Priority
interventions are to remove the patient’s clothes, brush loose chemical away from the skin and
apply water for at least 30 minutes. Water needs to washed away from the body, not be
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applied as compresses. Contacting poison control may be helpful
in obtaining more
information on the systemic effects of the chemical, but it is not a priority intervention.
Jewelry should be removed, but this is not as high a priority as removing the chemical and
stopping the chemical burning process through continuous flushing with water.
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DIF: Cognitive Level: Application
OBJ: Describe the pathophysiology of burns.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
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17. What is the most likely site to have a sheet graft applied?
a. Arm
b. Face
c. Leg
d. Chest
ANS: B
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A sheet graft is more likely to be used on the face and hands because the cosmetic effects are
more optimal. Meshed grafts are more commonly used elsewhere on the body (e.g., arm, leg,
chest, etc.).
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DIF:
OBJ:
TOP:
MSC:
Cognitive Level: Comprehension
Formulate a plan of care for the patient with a burn injury.
Nursing Process Step: Implementation
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NCLEX: Physiological Integrity
18. The nurse is caring for a patient who has undergone skin grafting of the face and arms for
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burn wound treatment. What is a primary nursing diagnosis
for this patient?
a. Altered nutrition, less than body requirements
b. Body image disturbance
c. Decreased cardiac output
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d. Fluid volume deficit
ANS: B
Burns, scarring, and skin grafting can all affect appearance.
Body image disturbances may
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result. Nutritional support is started early in management of the patient with burns, and there
is no indication that this patient has a nutritional deficit. Nursing care plan priorities would
also continue to focus on nutritional needs to optimize healing. Decreased cardiac output and
fluid volume deficit should not be priority concerns duringabirb.com/test
the wound closure phase of burn
wound management by grafting.
DIF: Cognitive Level: Application
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OBJ: Relate the nursing diagnoses, outcomes, and interventions for the burned patient.
TOP: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
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19. The nurse is assisting the patient who is recovering from moderate burns to select foods from
the menu that will promote wound healing. Which statement indicates the nurse’s knowledge
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of nutritional goals?
a. “Avoid foods that have saturated fats. Fats interfere with the ability of the burn
wound to heal.”
b. “Choose foods that are high in protein, such as meat, eggs, and beans. These help
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the burns to heal.”
c. “It is important to choose foods like bread and pasta that are high in carbohydrates.
These foods will give you energy and help you to heal faster.”
d. “Select foods that have lots of fiber, such as whole grains
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and fruits. These will
promote removal of toxins from the body that interfere with healing.”
ANS: B
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Nutritional therapy must be instituted immediately after burn
injury to meet the high
metabolic demands of the body. Oral diets should be high in calories and high in protein to
meet the demands of the body.
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DIF: Cognitive Level: Application
OBJ: Formulate a plan of care for the patient with a burn injury.
TOP: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
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20. A burn patient in the rehabilitation phase of injury is increasingly anxious and unable to sleep.
The nurse should consult with the provider to further assess the patient for what possible
mental health condition?
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a. Acute delirium
b. Posttraumatic stress disorder
c. Suicidal intentions
d. Bipolar disorder
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ANS: B
Burn-injured patients experience psychologically devastating injuries in addition to physical
injuries. Burn patients that demonstrate changes in behavior,
anxiety, insomnia, regression,
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and acting out should be evaluated for posttraumatic stress disorder. Acute delirium is more
likely to occur during the acute phase of injury. Suicidal ideations should always be addressed
if the patient expresses or shows signs of suicidal thoughts. Burn-injured patients may have an
underlying mental health disorder that requires treatment, abirb.com/test
such as bipolar disorder or
schizophrenia.
DIF:
OBJ:
TOP:
MSC:
Cognitive Level: Application
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Formulate a plan of care for the patient with a burn injury.
Nursing Process Step: Implementation
NCLEX: Physiological Integrity
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21. The nurse is planning care to meet the patient’s pain management needs related to burn
treatment. The patient is alert, oriented, and follows commands. The pain is worse during the
day when various treatments are scheduled. Which statement to the primary healthcare
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provider (PCP) best indicates the nurse’s knowledge of pain
management for this patient?
a. “Can we ask the music therapist to come by each morning to see if that will help
the patient’s pain?”
b. “The patient’s pain is often unrelieved. I suggest that we
also add benzodiazepines
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to the opioids around the clock.”
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WWW.THENURSINGMASTERY.COM
c. “The patient’s pain is often unrelieved. It would be best if we can schedule the
opioids around the clock.”
d. “The patient’s pain varies depending on the treatment abirb.com/test
given. Can we try
patient-controlled analgesia to see if that helps the patient better?”
ANS: D
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Patient-controlled analgesia allows the patient with burns to
self-medicate for pain, thus
providing independence with pain management strategies. Nonpharmacological pain
strategies may provide helpful adjuncts to pain interventions. Scheduled pain medications and
anxiolytic agents, although helpful, do not put the control of pain management with the
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patient.
DIF: Cognitive Level: Application
OBJ: Formulate a plan of care for the patient with a burn injury.
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TOP: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
22. The nurse is conducting an admission assessment of an 82-year-old patient who sustained a
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12% burn from spilling hot coffee on the hand and arm. Which
statement is of priority to
assist in planning treatment?
a. “Do you live alone?”
b. “Do you have any drug or food allergies?”
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c. “Do you have a heart condition or heart failure?”
d. “Have you had any surgeries?”
ANS: C
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Many variables influence the outcome of elderly burn patient mortality, including preinjury
hydration status, nutrition status, and comorbid diseases, especially heart failure. Assessment
questions should include, as a priority, information about the patient’s cardiovascular status,
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including heart failure. Obtaining food or drug allergy information
is also important along
with other past medical history, including past surgeries. Information on the patient’s living
arrangements is an important safety consideration for discharge planning.
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DIF: Cognitive Level: Application
OBJ: Formulate a plan of care for the patient with a burn injury.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
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23. A 63-year-old patient is admitted with new onset fever; flulike symptoms; blisters over her
arms, chest, and neck; and red, painful, oral mucous membranes. The patient should be further
evaluated for which possible non–burn injured skin disorder?
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a. Toxic epidermal necrolysis
b. Staphylococcal scalded skin syndrome
c. Necrotizing soft tissue infection
d. Graft versus host disease
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ANS: A
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Patients with toxic epidermal necrolysis, Stevens-Johnson Syndrome (SJS), and erythema
multiforme present with acute onset fever and flulike symptoms, with erythema and blisters
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developing within 24 to 96 hours, skin and mucous membranes
slough, resulting in a
significant and painful partial-thickness injury. Staphylococcal scalded skin syndrome
presents predominantly in children. Necrotizing soft tissue infection results from rapidly
invasive bacterial infections. Graft versus host disease is not logical given the clinical
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information provided.
DIF:
OBJ:
TOP:
MSC:
Cognitive Level: Comprehension
Review the anatomy and physiology of the integumentary
system.
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Nursing Process Step: Implementation
NCLEX: Physiological Integrity
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24. What type of burn is capable of producing either a superficial
cutaneous injury or a
cardiopulmonary arrest and transient but severe central nervous system deficits?
a. Chemical burn
b. Electrical burn
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c. Heat burn
d. Infection
ANS: B
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Tissue damage results from the conversion of electrical energy into heat. Monitor the patient
for cardiac dysrhythmias.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process Step: Assessment
MULTIPLE RESPONSE
OBJ: Describe theabirb.com/test
pathophysiology of burns.
MSC: NCLEX: Physiological Integrity
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1. Which of the following statements about the pain management of a burn victim are true?
(Select all that apply.)
a. Additional pain medication may be needed because ofabirb.com/test
rapid body metabolism.
b. Pain medication should be given before procedures such as debridement, dressing
changes, and physical therapy.
c. Patients with a history of drug and alcohol abuse will require
higher doses of pain
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medication.
d. The intramuscular route is preferred for pain medication administration.
e. Oral medication is the preferred administration route
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ANS: A, B, C
The rapid metabolism associated with burn injury may require additional pain medication.
Many of the procedures associated with burn wounds are painful, such as dressing changes.
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Adequate pain medication should be given prior to the procedures.
Edema in burned patients
alters the absorption of medications that are injected intramuscularly; therefore, drugs must be
administered by the IV route.
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DIF:
OBJ:
TOP:
MSC:
Cognitive Level: Application
Relate the nursing diagnoses, outcomes, and interventions for the burned patient.
Nursing Process Step: Implementation
NCLEX: Physiological Integrity
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WWW.THENURSINGMASTERY.COM
2. Which of the following factors increase the burn patient’s risk for venous thromboembolism?
(Select all that apply.)
a. Burn injury less than 10%
b. Bedrest
c. Burns to lower extremities
d. Electrical burn injury
e. Delayed fluid resuscitation
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ANS: B, C, E
Venous thromboembolism (VTE) is a significant risk for patients who have thermal injury,
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venous stasis associated with immobility/bedrest, hypercoagulability seen with burn injuries
greater than 10% TBSA, and hypovolemia associated with delayed fluid resuscitation. Burns
to lower extremities will limit mobility and use of sequential compression devices, increasing
the potential risk for VTE. Electrical burn injury may poseabirb.com/test
a risk for VTE; however, VTE is
more closely associated with thermal injuries greater than 10% TBSA.
DIF: Cognitive Level: Application
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OBJ: Formulate a plan of care for the patient with a burn injury.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
3. The nurse is caring for a patient with burns to the hands, feet,
and major joints. The nurse
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plans care to include which intervention? (Select all that apply.)
a. Applying splints that maintain the extremity in an extended position
b. Implementing passive or active range-of-motion exercises
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c. Keeping the limbs as immobile as possible
d. Wrapping fingers and toes individually with bandages
e. Administering muscle relaxants around the clock
ANS: A, B, D
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It is important to avoid immobility in patients with burns of the hands, feet, or major joints.
Measures must be taken to maintain the function of the hands, feet, and major joints. Nursing
interventions to maintain range of motion, applying splits abirb.com/test
to keep the extremities in a position
of function, and individually wrapping fingers and toes are necessary to maintain function of
the hands, feet, and joints. Effective pain management is necessary to encourage mobility.
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DIF: Cognitive Level: Application
OBJ: Formulate a plan of care for the patient with a burn injury.
TOP: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
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4. Which infection control strategy should the nurse implement
to decrease the risk of infection
in the burn-injured patient? (Select all that apply.)
a. Apply topical antibacterial wound ointments/dressings.
b. Change indwelling urinary catheter every 7 days.
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c. Daily assess the need for central IV catheters.
d. Restrict family visitation.
e. Maintain strict aseptic technique during burn wound management.
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ANS: A, C, E
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Nurses can help reduce the risk of infection by using topical antibacterial wound ointments
and dressings as prescribed, daily questioning the need for invasive devices such as central IV
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access and indwelling urinary catheters, and maintaining aseptic
technique during all care
provided to the patient. Changing the indwelling urinary catheter will not reduce the risk of
infection; wound care is achieved by aseptic technique; and restricting family is not an
intervention related to infection prevention.
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DIF: Cognitive Level: Application
OBJ: Discuss the primary and secondary survey assessments during resuscitation and the acute
phases of burn management.
TOP: Nursing Process
Step: Implementation
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MSC: NCLEX: Physiological Integrity
5. Which complication may manifest after an electrical injury? (Select all that apply.)
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a. Long bone fractures
b. Cardiac dysrhythmias
c. Hypertension
d. Compartment syndrome of extremities
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e. Dark brown urine
f. Peptic ulcer disease
g. Acute cataract formation
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h. Seizures
ANS: A, B, D, E, G, H
Electrical injuries vary in severity of injury by the intensity of energy exposed to the body.
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Manifestations and complications may include cardiac dysrhythmias
arrest, hypoxia, deep tissue necrosis, rhabdomyolysis and acute kidney injury, compartment
syndrome, long bone fractures, acute cataract formation, and neurological deficits (including
seizures). Hypertension and peptic ulcer disease are not direct
consequences of electrical burn
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injuries.
DIF: Cognitive Level: Application
OBJ: Compare types of burn injuries.
TOP: Nursing Process Step: Implementation
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MSC: NCLEX: Physiological Integrity
6. An autograft is used to optimally treat a partial- or full-thickness wound that meets what
criteria? (Select all that apply.)
a. Involves a joint.
b. Involves the face, hands, or feet.
c. Is infected.
d. Requires more than 2 weeks for healing.
e. Involves very large surface areas
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ANS: A, B, D
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Autograft skin will allow for faster healing with less scar formation and a shorter
hospitalization. Grafting is not done while a burn is infected. There may not be enough
healthy skin to graft large areas.
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DIF:
OBJ:
TOP:
MSC:
Cognitive Level: Comprehension
Formulate a plan of care for the patient with a burn injury.
Nursing Process Step: Implementation
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NCLEX: Physiological Integrity
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WWW.THENURSINGMASTERY.COM
ORDERING
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1. What is the correct priority order of actions in prehospital primary survey for burn injuries?
(Put a comma and space between each answer choice.)
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a. Assess ABCs and cervical spine.
b. Provide oxygen therapy if smoke inhalation is suspected.
c. Make rapid head-to-toe assessment to rule out additional trauma.
d. Stop the burning process and prevent further injury. abirb.com/test
ANS:
D, A, B, C
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Early care has a positive impact on recovery. The first priority is to stop the burning process
and prevent further injury. At this point, you initiate the primary survey, which is to assess the
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ABCs and cervical spine. Oxygen therapy follows the ABCs.
The secondary survey includes
further assessment for additional injuries.
DIF: Cognitive Level: Analysis
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OBJ: Discuss the primary and secondary survey assessments during resuscitation and the acute
phases of burn management.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
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