Ch. 9 & 35 - Acute burn injuries

Question 1

A patient, being treated for burns over 40% of the total body surface area, is experiencing a hypermetabolic state. The nurse anticipates the addition of which type of medication to help reduce muscle wasting and accelerate healing time?

1. Antibiotics
2. Cardiac glycosides
3. Insulin
4. Calcium channel blockers

Answer 1

Correct Answer: 3

Rationale 1: Antibiotics are not the primary choice for this therapeutic effect.

Rationale 2: Cardiac glycosides may be indicated for this patient, but are not the drug class of choice for this therapeutic effect.

Rationale 3: Administration of insulin in severely burned patients has been shown to improve muscle protein synthesis, accelerate healing time, attenuate loss of lean body mass and decrease the acute phase response.

Rationale 4: Calcium channel blockers are not the drug class of choice for this therapeutic effect.

Question 2

Assessment of the patient’s sternal surgical incision reveals that the skin between sutures is opened. There is a small amount of drainage present on the dressing. The nurse would anticipate caring for this wound as it heals in which manner?

1. Tertiary intention
2. Primary intention
3. Secondary intention
4. Recurrent surgical debridement

Answer 2

Correct Answer: 3

Rationale 1: Tertiary intention combines primary and secondary intention, often requiring the wound to be left open for a period of time, such as a few days.

Rationale 2: Primary intention healing occurs when the wound is closed and heals without interruption.

Rationale 3: This wound has dehisced, which means that it has not healed as expected and the suture line is opened. This may occur because of stretching of the skin, poor skin integrity, or because the wound is infection. Dehisced sternal wounds are allowed to heal by second intention.

Rationale 4: Future surgical debridement may be necessary if the wound does not heal, but this is not an expected part of the plan of care.

Question 3

A patient is admitted with partial-thickness burns over the entire left arm and neck. Superficial burns are present on the face and scalp. The anterior truck has patches of superficial burns. There are deep partial-thickness burns on the legs with full-thickness burns on both feet. The nurse using the Lund and Browder chart to estimate the total body surface area burned will include the burns on which body areas? Select all that apply

1. Left arm
2. Face
3. Legs
4. Feet
5. Trunk

Answer 3

Correct Answer: 1,3,4

Rationale 1: Partial-thickness burns are included in this estimate.

Rationale 2: Superficial burns are not included in this estimate.

Rationale 3: Deep partial-thickness burns are included in this estimation.

Rationale 4: Full-thickness burns are included in this estimation.

Rationale 5: Superficial burns are not included in this estimation.

Question 4

The nurse assesses a burn patient’s urine to be reddish-brown in color. Which interventions would the nurse anticipate? Select all that apply

1. Interventions to raise the urine pH to an alkaline level
2. Discontinuing orders for sodium bicarbonate
3. Irrigating the patient’s bladder with a sodium bicarbonate solution
4. Management of intravenous fluids to achieve a urine output of 75 mL per hour
5. Monitor for hypocalcemia.

Answer 4

Correct Answer: 1,5

Rationale 1: If a patient has experienced muscle damage from exposure to an electrical current or a crush-type injury, the urine may be a red to reddish-brown color. This discoloration results from myoglobin in the urine. The solubility of myoglobin increases in an alkaline environment, so maintaining alkaline urine will increase the rate of myoglobin clearance.

Rationale 2: The nurse would anticipate adding sodium bicarbonate to this patient’s treatment plan.

Rationale 3: Irrigating the patient’s bladder with sodium bicarbonate will not raise the urine pH.

Rationale 4: Adequate urine output of 75 to 100 mL per hour will help to increase the rate of myoglobin clearance.

Rationale 5: Treatment of myoglobinuria may result in hypocalcemia.

Question 5

The nurse caring for a patient with a pressure ulcer notes the wound is increasing in redness and has more swelling around the wound edges. Which nursing intervention is indicated?

1. Encourage the patient to ingest more fluids.
2. Assess for pain and warmth.
3. Cover the wound with a sterile dry dressing.
4. Dress the wound as prescribed.

Answer 5

Correct Answer: 2

Rationale 1: Encouraging fluids will not reduce the inflammation that is occurring in the wound.

Rationale 2: The cardinal signs of an inflammation exist in a wound that is infected and include redness, edema, pain, and warmth. Since the patient’s wound is demonstrating redness and edema, the nurse needs to assess for pain and warmth to aid in determining if the wound is inflamed and infected.

Rationale 3: Covering the wound with a sterile dry dressing will not address the potential for infection that exists.

Rationale 4: Simply dressing the wound according to previous order will not address the change that has occurred.

Question 5

The patient has been prescribed IV gentamicin for treatment of an aerobic gram-negative wound infection. Which nursing intervention is indicated?

1. Draw peak and trough concentrations as indicated.
2. Give the medication over a 2-hour period.
3. Hold the medication if the patient experiences nausea.
4. Monitor for increase in creatinine clearance.

Answer 5

Correct Answer: 1

Rationale 1: Gentamicin has a narrow therapeutic range. Peak and trough concentrations should be drawn.

Rationale 2: There is no indication that it is necessary to give this medication over 2 hours.

Rationale 3: There is no indication that nausea will require interrupting therapy.

Rationale 4: Decreased creatinine clearance is the adverse effect associated with gentamicin.

Question 6

A patient is to receive pulsatile lavage treatments for a chronic ulcer on the left heel. Which explanation would the nurse provide for this treatment?

1. “This treatment is a form of autolytic debridement to remove dead tissue from your heel.”
2. “Your foot will be submersed in a whirlpool tub for this treatment.”
3. “This treatment will help cleanse the wound bed.”
4. “This treatment will inject medications into the deep crevices of your wound.”

Answer 6

Correct Answer: 3

Rationale 1: Pulsatile lavage is not a form of autolytic debridement.

Rationale 2: Whirlpool tubs are not used for pulsatile lavage. Whirlpool treatments increase risk of cross contamination of the wound.

Rationale 3: Pulsatile lavage is used to clean materials out of the wound bed.

Rationale 4: Pulsatile lavage is not used to inject medications into the wound.

Question 6

The surgical wound of a patient recovering from an appendectomy has several steri-strips across it with a small amount of dried blood over the incision line. How would the nurse dress this wound?

1. Hydrocolloid dressing
2. Wet-to-dry dressing
3. Alginate dressing
4. Dry, sterile dressing

Answer 6

Correct Answer: 4

Rationale 1: Hydrocolloid dressings are used on moderate to heavily exudating wounds. This wound is dry.

Rationale 2: Wet-to-dry dressings are used for wounds that are healing by second intention.

Rationale 3: Alginate dressings are used to absorb secretions and form a covering for the wound bed. This wound bed is dry.

Rationale 4: The patient’s wound is healing by primary intention. Dry, sterile dressings are the standard for wounds healing by this method, offering protection from contamination and the absorption of the minimal amount of exudate expected.

Question 6

The nurse is caring for a patient admitted with thermal burns. The nurse will plan to monitor the patient closely over the next 2 to 3 days for development of which most serious complication?

1. Pain
2. Burn shock
3. Continuation of the burn process below the level of obvious injury
4. Hypervolemia

Answer 6

Correct Answer: 2

Rationale 1: Thermal burns are painful, but this is not the most serious complication listed.

Rationale 2: Thermal burns produce microvascular and inflammatory responses within minutes of the injury; however, the effects from these two responses can last from 2 to 3 days. Substances released by damaged cells increase vascular permeability, causing fluid, electrolytes, and proteins to leak into the interstitial space. The fluid shift from intravascular to interstitial spaces may cause a hypovolemic shock state, which is frequently referred to as burn shock.

Rationale 3: Continuation of the burn process below the level of obvious injury is a characteristic of an alkaline burn not a thermal burn.

Rationale 4: It would be more likely that the patient would develop hypovolemia.

Question 6

The nurse is planning the care of a patient who has burns to the face, neck, upper chest, and both upper arms. To prevent contracture development, the nurse should include which interventions in the patient’s plan of care? Select all that apply.

1. Use a bed cradle over the burned areas.
2. Have patient assume the position of comfort while sleeping.
3. Administer analgesics prior to physical therapy.
4. Instruct the patient to avoid using pillows under the head.
5. Get the patient out of bed as soon as medically feasible.

Answer 6

Correct Answer: 3,4,5

Rationale 1: Using bed cradles is effective in preventing infection and irritation of burn wounds, but it has no direct effect on preventing contractures.

Rationale 2: The position of comfort is most often flexion, which should be avoided at all times.

Rationale 3: Physical therapy can be painful for patients with burns. Reducing the pain can help the patient be more participative in therapy sessions.

Rationale 4: Using pillows under the head leads to hyperflexion of the neck and burned surfaces will be touching each other. This may lead to developing contractures of the neck.

Rationale 5: Getting the patient out of bed and using the joints is the best way to prevent development of contracture. Total body mobilization is also beneficial to cardiopulmonary functioning.

Question 7

A nurse documents a stage 1 pressure ulcer on a patient’s lateral malleolus. What assessment findings would indicate that this ulcer has progressed to stage II?

Standard Text: Select all that apply.

1. The subcutaneous fat layer is exposed.
2. A fluid-filled blister is present.
3. A shallow open ulcer is present.
4. There is an area of boggy purple skin on the bony prominence.
5. There is an area of skin that does not turn white with pressure.

Answer 7

Correct Answer: 2,3

Rationale 1: Exposure of the subcutaneous fat layer occurs in stage III ulcers.

Rationale 2: Presence of a fluid-filled blister indicates a stage II ulcer.

Rationale 3: Shallow open ulcers are stage II ulcers.

Rationale 4: Boggy purple skin over a bony prominence is a deep-tissue injury.

Rationale 5: Nonblanchable erythema indicates a stage I ulcer.

Question 8

A patient with several burn scars tells the nurse that the scars are prone to injury and don’t seem as tough as the rest of his skin. Which nursing response is indicated?

1. “Even when healed, the scar will only regain about 80% of the strength of normal skin.”
2. “Your body is still making new blood vessels for the wound.”
3. “Your body is trying to remove additional bacteria from the wound area.”
4. “Your healing process hasn’t been completed.”

Answer 8

Correct Answer: 1

Rationale 1: Remodeling/maturation is the final repair process and can last months to years. The final product of remodeling is the scar, which has covered the defect and restored the protective barrier against the external environment. Even when the wound is completely healed, only about 80% of the tensile strength of normal skin is regained and the patient is at risk for recurrent breakdown.

Rationale 2: Angiogenesis takes place in the proliferative stage of wound healing, not after scars have developed.

Rationale 3: Bacterial are normally removed from the wound during the inflammatory phase.

Rationale 4: The patient’s healing process may take months or years, but this is not the best answer to address the patient’s concerns.

Question 8

The wound care specialist has assessed a patient’s pressure ulcer and recommends using a hydrocolloid wafer to encourage autolytic debridement. The nurse would plan interventions associated with which stage pressure ulcer?

1. Stage I
2. Stage II
3. Stage III
4. Stage IV

Answer 8

Correct Answer: 4

Rationale 1: Stage I ulcers are treated with turning and removal of pressure.

Rationale 2: Stage II ulcers need a moist environment but not debridement.

Rationale 3: Stage III ulcers need a moist environment but not debridement.

Rationale 4: Stage IV ulcers may require debridement as well as packing to fill dead space and to absorb exudate.

Question 10

The patient’s colectomyincision is red and the skin around the sutures is taut and shiny. What nursing intervention is indicated?

1. Assess for the presence of drainage or odor.
2. Clean this healing wound and redress as ordered.
3. Collaborate with the health care provider regarding suture removal.
4. Instruct the patient to use additional splinting for deep breathing and coughing.

Answer 10

Correct Answer: 1

Rationale 1: Since this patient’s surgical wound is closed with sutures the nurse should assess for the odor of GI contents or for seepage around the sutures. If this finding is present and enterocutaneous fistula may be present.

Rationale 2: These findings do not indicate a healing wound.

Rationale 3: These findings are not those normally associated with a wound ready for suture removal.

Rationale 4: These findings do not indicate stress from coughing and they will not be changed by additional splinting.

Question 12

Victims of a house fire are being admitted through the emergency department. Of the patients, the nurse realizes that which will have the greatest general risk for mortality from the burn injuries?

1. 25-year-old pregnant female
2. 49-year-old male who smokes
3. 75-year-old female with arthritis
4. 50-year-old male with coronary artery disease

Answer 12

Correct Answer: 3

Rationale 1: Pregnancy is not a factor in increasing mortality from burn injury.

Rationale 2: This patient does not have the greatest risk of mortality from this burn injury.

Rationale 3: People of advancing age have thinner skin, with decreased microcirculation and an increased susceptibility to infection. All of these factors not only put them at a greater risk for burn injuries, but also lead to a greater morbidity and mortality.

Rationale 4: Coronary artery disease does not make this patient at higher risk than another patient also injured in this fire.

Question 14

A patient is rehabilitating after a severe burn 6 months ago that left her with scars across her chest and abdomen. She says, “I don’t care what people think, I am going to the beach in a bikini next week.” What most important information should the nurse provide?

1. “This may be difficult since you are still supposed to be wearing your compression garment.”
2. “You need to avoid sun exposure to your scars for at least one year.”
3. “You should prepare yourself for how others will react to your scars.”
4. “Remember that you are prone to getting too hot easily.”

Answer 14

Correct Answer: 2

Rationale 1: The patient probably is still supposed to be wearing her compression garment, but this is not the most important consideration.

Rationale 2: Scars should be protected from sun exposure for one year or until the scar turns silvery white. Otherwise the scar will “tan” and remain permanently pigmented, leaving a less than satisfactory cosmetic result.

Rationale 3: This is an important consideration but is not the most important information for the nurse to share.

Rationale 4: This may be the case, but it is not the most important information for the nurse to share.

Question 15

A patient, recovering from being struck by lightning 36 hours prior to admission, is demonstrating an acute onset of confusion and muscle weakness. Which rationale would the nurse provide for this assessment?

1. The patient has is suffering a stroke unrelated to the injury.
2. The patient likely has an electrolyte imbalance.
3. The patient has developed a seizure disorder from the injury.
4. The patient is having delayed onset of neurological symptoms, which are common after a lightning injury.

Answer 15

Correct Answer: 4

Rationale 1: There is not enough information for the nurse to determine that the patient is suffering a stroke.

Rationale 2: Without more information the nurse cannot attribute this finding to an electrolyte imbalance.

Rationale 3: This assessment does not support the diagnosis of a seizure disorder.

Rationale 4: Neurological effects are common with electrical and lightning injuries. The onset of clinical manifestations may be acute or delayed. Patients may experience confusion, exhibit a flat affect, lose the ability to concentrate, or have short-term memory problems. Seizures, headaches, peripheral nerve damage, and loss of muscle strength may also be observed.

Question 16

During initial assessment the nurse notes that the edges of a wound are hard to palpation. The nurse would continue assessment for which conditions? Select all that apply

1. Infection
2. Necrosis
3. Osteomyelitis
4. Deep tissue injury
5. Maceration

Answer 16

Correct Answer: 1,2,4

Rationale 1: Indurated wound edges may indicate infection.

Rationale 2: Indurated edges may indicate necrosis.

Rationale 3: Osteomyelitis is considered when bone is visible or palpable.

Rationale 4: Indurated wound edges may occur when there is deep tissue injury.

Rationale 5: Maceration is softening of the skin associated with chronic exposure to moisture.

Question 17

A patient with severe deep partial-thickness burns is scheduled for hydrotherapy at 10:00 a.m. every day. The patient has an order for Percocet (oxycodone and acetaminophen) two tablets by mouth every 4 to 6 hours PRN for pain. When developing the nursing care plan, the nurse should include which nursing order?

1. Administer two tablets of Percocet at 11:00 a.m. every day right after hydrotherapy.
2. Administer two tablets of Percocet at 10:00 a.m. every day prior to hydrotherapy.
3. Administer two tablets of Percocet at 9:00 a.m. every day prior to hydrotherapy.
4. Administer two tablets of Percocet at 9:45 a.m. every day prior to hydrotherapy.

Answer 17

Correct Answer: 3

Rationale 1: Giving Percocet after the procedure may decrease its effectiveness because it is easier to control pain before it becomes severe.

Rationale 2: Administering pain medication at the beginning of a painful procedure will not effectively manage the pain from the treatment.

Rationale 3: The nurse should plan to administer the pain medication prior to a painful procedure. Because it takes about 45 to 60 minutes for an oral medication to be absorbed, the nurse should plan to give Percocet at 9:00 a.m. every day, one hour prior to hydrotherapy.

Rationale 4: More time is needed in order for the Percocet to be effective.

Question 17

The nurse caring for a patient admitted for burns over his torso and upper arms has clothing adhered to the skin. Which nursing action is indicated?

1. Leave the clothing in place and flush the areas with cooled water
2. Flush the clothing with hydrogen peroxide to clean the skin underneath
3. Cover the areas with gauze
4. Apply a topical antiseptic over the clothing areas

Answer 17

Correct Answer: 1

Rationale 1: Clothing, jewelry, belts, or anything containing heat is removed from the patient however adhered clothing or tar is left in place and cooled with water because removing it will cause further damage to the skin.

Rationale 2: The nurse should not use hydrogen peroxide on this wound.

Rationale 3: Simply covering the areas with gauze is an insufficient intervention.

Rationale 4: Applying a topical antiseptic over the clothing is an insufficient intervention.

Question 18

A patient is admitted for a repair of an abdominal aortic aneurysm. Which assessment finding would the nurse evaluate as indicating this patient is at increased risk for developing an enterocutaneous fistula (ECF)?

1. Diagnosis of type 2 diabetes mellitus
2. Daily use of NSAIDs for arthritis symptoms
3. Diagnosis of peripheral vascular disease
4. History of radiation therapy to treat colon cancer

Answer 18

Correct Answer: 4

Rationale 1: While diabetes mellitus can result in impaired healing, it is not a specific risk for development of ECF.

Rationale 2: There is no specific connection between use of NSAIDs and increased risk for ECF.

Rationale 3: Peripheral vascular disease can result in problems with skin integrity, but is not a specific risk for development of ECF.

Rationale 4: Radiation therapy to the abdomen increases the patient’s risk for development of ECF.

Question 19

The nurse is providing emergency care to patients injured in a house fire. Which patient would the nurse prepare for transfer to a burn center for additional care and treatment?

1. 15-year-old child with 5% total body surface area burns to the left arm
2. 10-year-old child with partial-thickness burns to the left hand
3. 30-year-old female with superficial burns to the arms, face, and neck
4. 35-year-old male with partial-thickness burn to a part of his back.

Answer 19

Correct Answer: 2

Rationale 1: The child with 5% total body surface burn to the left arm would not need to be transferred to the burn center since the total body surface area is less than 10%.

Rationale 2: The 10-year-old child would fulfill the burn center referral criteria for transfer to a burn center because the child has burns to the face and hands.

Rationale 3: Superficial burns can typically be addressed in a non-burn unit environment.

Rationale 4: Referral is considered when a partial-thickness burn occurs to more than 10% of TBSA.

Question 20

The nurse measures a patient’s wound diameter and notes that it has reduced in size. The nurse evaluates this information to indicate the wound has entered which phase?

1. Remodeling
2. Inflammatory
3. Maturation
4. Proliferative

Answer 20

Correct Answer: 4

Rationale 1: The remodeling phase is the third phase of the wound healing process occurs after the wound has closed.

Rationale 2: The inflammatory phase prepares the wound environment for subsequent tissue development. This sign is recognized by the four cardinal signs of inflammation: heat, redness, swelling, and pain.

Rationale 3: The maturation stage is also known as the remodeling stage.

Rationale 4: Wound contraction occurs during the proliferative phase of wound healing.

Question 21

A patient has a wound on his thigh that is swollen and red. The nurse assesses that the surrounding tissue has a dusky blue color with a few small dark blisters. Which other assessment findings would cause the nurse to alert the health care provider about possible necrotizing fasciitis (NF)? Select all that apply

1. Blood pressure is 140/90 mm Hg.
2. The patient reports recently taking steroids for a severe ear infection.
3. The patient works in an elementary school.
4. The patient reports pain as a 9 on the 1 to 10 pain scale.
5. The patient’s body mass index is 31.

Answer 21

Correct Answer: 2,4,5

Rationale 1: If the patient is in pain this blood pressure would not be unexpected.

Rationale 2: Steroid use increases the risk for necrotizing fasciitis.

Rationale 3: Exposure to young children is not a risk factor for developing necrotizing fasciitis.

Rationale 4: Pain that is out of proportion to the physical clinical presentation is an important warning sign of NF.

Rationale 5: A body mass index (BMI) over 30 indicates obesity. Obesity is a risk factor for development of NF.

Question 22

A patient presents to the emergency department with a large leg wound. The nurse identifies which factors as increasing this patient’s risk of complications with wound healing? Select all that apply

1. The patient smokes eight cigarettes a day.
2. The patient has peripheral artery disease.
3. The patient has osteoarthritis in his knees.
4. The patient’s average blood sugar measurements are over 200mcg/dL.
5. The patient lost some blood during the injury but the loss was not excessive.

Answer 22

Correct Answer: 1,2,4

Rationale 1: Smoking byproducts such as nicotine, carbon monoxide, and hydrogen cyanide reduce oxygenation, impair immune response, reduce fibroblast activity, and increase platelet adhesion and thrombus formation. This reduces oxygenation to the tissues. Smoking is also associated with significantly higher infection rates.

Rationale 2: Peripheral artery disease decreases oxygenation of the tissues, increasing risk of complications.

Rationale 3: The presence of osteoarthritis is related to overuse of the joint and is not a significant risk factor for problems healing.

Rationale 4: Poor glycemic control as evidenced by average blood sugar measurements over 200 mcg/dL is a factor in healing problems.

Rationale 5: Significant blood loss to the point of hypovolemia can cause decreased oxygenation of tissues, leading to difficulties with healing.

Question 23

A male patient tells the nurse that he has “excruciating pain” in his perineal region that started a few days after having an indwelling urinary catheter removed. Upon inspection, the nurse sees a dime-sized reddened area on the patient’s perineum below the scrotal sac. What nursing intervention is priority?

1. Have the wound further evaluated for possible Fournier’s gangrene.
2. Apply ice to the region.
3. Give the patient prn acetaminophen.
4. Place a scrotal support on the patient.

Answer 23

Correct Answer: 1

Rationale 1: The one clinical symptom of Fournier’s gangrene is pain out of proportion to the wound. The other clinical symptom is that this type of disorder affects males more than females. These two pieces of information should lead the nurse to contact the patient’s physician for further evaluation of the wound for possible Fournier’s gangrene. The patient did have an indwelling urinary catheter removed a few days ago and this type of disorder is associated with genitourinary procedures or manipulation.

Rationale 2: Applying ice to the region is not indicated.

Rationale 3: The nurse would treat the patient’s pain, but a different intervention is the priority.

Rationale 4: There is no indication that use of a scrotal support would relieve this patient’s pain or change the underlying reason for the pain.

Question 25

A patient is being admitted for treatment of deep partial-thickness burns. When doing this patient’s initial assessment, the nurse would expect which burn characteristics? Select all that apply

1. Sluggish capillary refill
2. Leathery, white tissue
3. Significant edema
4. Blisters
5. Erythema

Answer 25

Correct Answer: 1,3,5

Rationale 1: The deep partial-thickness burn damages capillaries. Capillary refill may be sluggish or absent.

Rationale 2: Leathery, white tissue is characteristic of full-thickness burns.

Rationale 3: Deep partial-thickness burns result in a significant amount of edema.

Rationale 4: No blisters are present in deep partial-thickness burns.

Rationale 5: Erythema can be present with these burns, or the tissues may be pale.

Question 26

The nurse is preparing to ambulate a patient who sustained burns over 20% of his lower extremities. Which intervention is most important to facilitate the success of the patient’s ambulation?

1. Transfer the patient to a chair before ambulating.
2. Apply compression wraps to the lower extremities before getting out of bed.
3. Be certain the patient is well-hydrated before ambulation.
4. Have the patient perform incentive spirometry.

Answer 26

Correct Answer: 2

Rationale 1: Transferring the patient to a chair before ambulating may or may not be necessary.

Rationale 2: It is important to apply compression wraps on lower extremities before getting the patient out of bed in order to prevent venous stasis. If extremities are not wrapped, the patient is at risk for capillary bed bleeding, which could cause autograft failure or delay donor-site healing. Venous pooling coupled with prolonged immobility also predisposes the patient to deep-vein thrombosis. Wrapping the extremities continues until all wounds are healed and pressure garments are applied.

Rationale 3: The patient should always be well-hydrated, but hydration status is not the most important aspect of preparing a patient for ambulation.

Rationale 4: Use of incentive spirometry may help prevent development of pneumonia, but is not necessary in preparation for ambulation.

Question 27

A female patient recovering from a burn to the left side of her face tells the nurse that she has no idea how she is going to return home and resume her regular life since she is so “ugly and disfigured.” What nursing response is indicated?

1. “It is good that your work does not include having to meet the public everyday.”
2. “I don’t think your scars are so bad.”
3. “I think you should see a plastic surgeon before you try to go back to work.”
4. “Would you like a referral to the Phoenix Society?”

Answer 27

Correct Answer: 4

Rationale 1: This statement reinforces that the patient needs to “hide” from others and is not appropriate.

Rationale 2: This statement devalues the patient’s concern and is not appropriate.

Rationale 3: Suggesting plastic surgery reinforces the idea that the patient should not be seen in public and is not appropriate.

Rationale 4: The Phoenix Society maintains a registry of professionals who specialize in scar therapy and camouflage makeup techniques. This offer of a referral addresses the patient’s concerns, but puts the patient in charge of her decision.

Question 28

There is dead tissue throughout the patient’s nonhealing abdominal wound. The nurse prepares for which intervention needed to encourage this wound to heal?

1. Diet analysis for protein adequacy
2. Keeping the wound covered to increase oxygen to the wound bed
3. Debridement of devitalized tissue
4. Introduction of air into the wound for drying

Answer 28

Correct Answer: 3

Rationale 1: The patient does need adequate protein in order for healing to occur, but this is not the most problematic issue at present.

Rationale 2: Keeping the wound covered does help to maintain oxygen levels in the wound bed, but this is not the most problematic issue present.

Rationale 3: The patient has a compromised wound that contains devitalized tissue. Devitalized tissue is tissue that has been separated from the circulation and the body’s antimicrobial defenses. Bacteria proliferate on wounds that contain dead tissue and debridement of these materials is essential to prevent an environment conducive to bacterial growth.

Rationale 4: The wound bed should be kept moist.

Question 29

A civilian patient admitted with frostbite burns to his feet is receiving pain medication, fluid replacement, and is being monitored for any signs of organ dysfunction. What rationale would the nurse provide for this conservative management?

1. Frostbite injuries are not as serious as thermal or chemical burns.
2. The extent of the injury is not obvious.
3. Little is known about other methods to treat frostbite.
4. Aggressive frostbite management is only done in specialty military hospitals.

Answer 29

Correct Answer: 2

Rationale 1: Frostbite injuries can be devastating.

Rationale 2: Since it may take weeks before there is a clear demarcation between viable and nonviable tissue with frostbite injuries, patients are treated conservatively, which includes fluid support, pain management, and ongoing assessment of organ functioning.

Rationale 3: This treatment approach is not related to lack of knowledge of other potential treatments.

Rationale 4: Hospitals of all descriptions generally approach frostbite care conservatively.

Question 30

The nurse caring for a patient who sustained burns of 30% of the total body surface area seven days ago is assessing the status of the patient’s wounds. Which phase of wound healing would the nurse expect to be occurring?

1. Contraction
2. Inflammatory
3. Maturation
4. Proliferative

Answer 30

Correct Answer: 2

Rationale 1: Contraction is not a phase of wound healing

Rationale 2: The inflammatory phase lasts approximately 2 weeks.

Rationale 3: The maturation phase of wound healing can last 6 to 18 months or longer depending on the wound.

Rationale 4: The proliferative phase begins after about two weeks and may last up to 1 month.

Question 32

The nurse manager has noted an increase in wound infections in a postoperative unit. What instruction to the unit staff is the most important?

1. Wear gloves at all times.
2. Administer antibiotics as prescribed.
3. Assess patients for infection risk upon admission.
4. Follow hand washing protocols.

Answer 32

Correct Answer: 4

Rationale 1: Wearing gloves at all times could increase infection rate by creating a false sense of security among staff. If other infection control methods are not used, the constant presence of gloves could increase cross-contamination.

Rationale 2: Antibiotics should be given as prescribed, but this is not the most important intervention.

Rationale 3: Knowing which patients are at highest risk for infection is helpful, but is not the most critical intervention.

Rationale 4: Correct hand washing is still considered one of the most important methods of preventing wound infections.

Question 33

A patient has been treated in the burn unit for 3 months. What characteristics of wound healing would the nurse evaluate as normal? Select all that apply

1. Organization of collagen layers
2. Reepithelialization
3. Revascularization
4. Strengthening of the scar
5. Keloid production

Answer 33

Correct Answer: 1,4

Rationale 1: The patient should be in the maturation stage of wound healing, which is characterized by the organization of collagen layers.

Rationale 2: Reepithelialization occurs in the proliferative stage. This stage should be completed.

Rationale 3: Revascularization occurs in the proliferative stage.

Rationale 4: Strengthening of the scar occurs during the maturation phase, which should be happening at this point after injury.

Rationale 5: Keloids may occur during this stage, but this is not a normal finding.

Question 35

A patient has a wound that extends into the subcutaneous fatty tissue. The nurse plans care for this wound with the knowledge that it has penetrated to which skin level?

1. Epidermis
2. Hypodermis
3. Dermis
4. Cartilage

Answer 35

Correct Answer: 2

Rationale 1: The epidermis, the outermost layer, contains epithelial cells.

Rationale 2: The hypodermis contains blood vessels, nerves, muscle, and adipose tissue.

Rationale 3: The dermis contains connective tissue and elastic fibers, sensory and motor nerve endings, and a complex network of capillary and lymphatic vessels and muscles.

Rationale 4: Cartilage is not a layer of the skin.

Question 36

The nurse is caring for a 154-pound patient with 50 percent total body surface area burns. If using the Parkland formula, the nurse will calculate which amount of intravenous solution to provide this patient in the first 24 hours of care?

1. 14,000 mL
2. 42,000 mL
3. 3,500 mL
4. 7,000 mL

Answer 36

Correct Answer: 1

Rationale 1: Based on the Parkland formula, the total amount of fluids required in the first 24 hours = 4 mL of Ringer’s lactate × TBSA of burns × patient’s weight in kgs. For this patient, 4 mL × 50 × 70 kg = 14,000 mL; 7, 000 mL should be given in the first 8 hours; 3,500 mL in the second 8 hours; and 3,500 mL in the last 8 hours.

Rationale 2: This is an inaccurate calculation based on this patient’s weight and TBSA.

Rationale 3: This patient will require 3,500 mL in the last 8-hour period of the next 24 hours, not for the entire 24 hours.

Rationale 4: This patient will require 7, 000 mL of fluid in the first 8 hours of the next 24 hours.

Question 37

A patient comes into the emergency department with severe burns over the face, arms, legs, and back after spending the day boating with friends. The skin is dry and very red with brisk capillary refill. How would the nurse classify this patient’s burn injuries?

1. Superficial
2. Deep partial thickness
3. Superficial partial thickness
4. Full thickness

Answer 37

Correct Answer: 1

Rationale 1: Superficial burns involve the epidermis only and are associated with burns from the sun. The burns are red and no blisters are present.

Rationale 2: Deep partial-thickness burns involve the epidermis and the deep layer of the dermis. They are caused by contact with flame, hot liquids, tar, or hot objects. Skin may be red or pale and capillary refill is sluggish or absent.

Rationale 3: Superficial partial-thickness burns involve the epidermis and papillary layer of the dermis and are caused by contact with hot objects, hot liquids, or flash flame. The skin is red with brisk capillary refill and blisters.

Rationale 4: Full-thickness burns involve the epidermis, dermis, and subcutaneous tissue. These are caused by contact with flame, electricity, or chemicals. The skin is dry and leathery or white with absent capillary refill.

Question 38

A patient being treated for necrotizing fasciitis has signs of granulation tissue appearing in a large abdominal wound. The nurse anticipates providing which care for this patient’s wound?

1. Irrigating the wound twice daily before applying dry dressing
2. Caring for a split thickness skin graft
3. Applying wet-to-dry dressings
4. Caring for a suture line created by surgical closure of the wound

Answer 38

Correct Answer: 2

Rationale 1: Granualtion tissue should be kept moist.

Rationale 2: Once systemic manifestations of the infectious process associated with necrotizing fasciitis disappear, healthy granulation tissue appears. The next phase is to restore dermal and fascial integrity and the best way to achieve wound closure rapidly and safely is with split thickness skin grafts. Skin is taken from a donor site and placed on healthy granulation tissue to cover the defect.

Rationale 3: The wounds associated with necrotizing fasciitis are large and would not easily be treated with wet-to-dry dressings.

Rationale 4: This wound will be extensive and is not closed in the normal manner of creating a suture line.

Question 39

A patient has full-thickness burns of the right chest area, entire right arm, and deep partial-thickness burns of both upper anterior legs. Based on the rule of nines, which estimate of total body surface area burn would the nurse record?

1. 36%
2. 27%
3. 45%
4. 18%

Answer 39

Correct Answer: 2

Rationale 1: This estimate is incorrect.

Rationale 2: According to the rules of nines, the right chest area = 9%, entire right arm = 9%, and the upper anterior legs = 4.5% + 4.5%. The total = 9 + 9 + 9 = 27%.

Rationale 3: This estimate is incorrect.

Rationale 4: This estimate is incorrect.