Chapter 55. Nursing Care of Patients With Burns

Chapter 55. Nursing Care of Patients With Burns

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

Multiple Choice

Identify the choice that best completes the statement or answers the question.

____     1.   The nurse is at the scene of a fire caring for a patient with a thermal burn on the face, chest, and abdomen. What action should the nurse perform first?

____     2.   The nurse is caring for a patient with burns covering the entire surface of both arms and the anterior trunk. Approximately what percentage of the patient’s body surface area has been affected?

____     3.   The nurse is caring for a patient in the initial phase of treatment for a partial-thickness burn. The patient has been stabilized, with blood pressure 140/88 mm Hg, pulse 78 beats/min, respirations 22 breaths/min, and temperature 97.4°F (36.3°C). Which new assessment finding should be immediately communicated to the health care provider (HCP)?

____     4.   The nurse is caring for a patient who is 2 days post-inhalation burn injury from a house fire. Which outcome best indicates that nursing interventions for impaired gas exchange have been effective?

____     5.   A patient is having a surgical procedure done to promote peripheral tissue perfusion in an extremity with full-thickness circumferential burns. What term should the nurse use to document this procedure?

MULTIPLE CHOICE

1. ANS:  A

Care should be provided according to the ABCs or airway, breathing, and circulation. B. C. D. The burn wound takes a lower priority to the ABCs (airway, breathing, circulation) of trauma resuscitation.

PTS:   1                    DIF:    Moderate

KEY:  Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

2. ANS:  C

According to the Rule of Nines, each arm is 9% and the anterior trunk is 18% for a total of 36%. A. B. D. These are inaccurate calculations using the Rule of Nines.

PTS:   1                    DIF:    Moderate

KEY:  Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

3. ANS:  D

A patient with a burn is at risk for fluid volume deficit, and a dropping blood pressure, even though it is still within normal limits, could be an early sign. A. B. Temperature and pain are concerns but are not immediately life threatening. C. Blister formation is expected.

PTS:   1                    DIF:    Moderate

KEY:  Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

4. ANS:  C

Poor oxygenation results in reduced level of consciousness and confusion, so an alert and oriented patient likely has safe gas exchange. B. D. Peripheral pulses and temperature are not directly affected by gas exchange. A. A PaCO₂ of 56 mm Hg shows poor gas exchange.

PTS:   1                    DIF:    Moderate

KEY:  Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Evaluation

5. ANS:  D

If the patient has a circumferential burn an increase in tissue pressure secondary to tissue edema occurs. The burn then acts like a tourniquet, impeding arterial and venous flow. An escharotomy is immediately necessary to relieve this pressure. An escharotomy is a linear excision through the eschar to the superficial fat that allows for expansion of the skin and return of blood flow. A. Excision refers to cutting something out. B. A skin graft places new skin over a burn site. C. Débridement removes dead tissue.

PTS:   1                    DIF:    Moderate

KEY:  Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application