Pregunta 1
Pregunta
The optimal measurement of intravascular fluid status during the immediate fluid resuscitation phase of burn treatment is
Pregunta 2
Pregunta
A patient admitted with severe burns to his face and hands is showing signs of extreme agitation. The nurse should explore the mechanism of burn injury possibly related to
Pregunta 3
Pregunta
The nurse is assisting the patient to select foods from the menu that will promote wound healing. Which statement indicates the nurse’s knowledge of nutritional goals?
Respuesta
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Choose foods that are high in protein, such as meat, eggs, and beans. These help the burns to heal.”
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“Avoid foods that have saturated fats. Fats interfere with the ability of the burn wound to heal.”
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It is important to choose foods such as bread and pasta that are high in carbohydrates. These foods will give you energy and help you to heal faster.”
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Select foods that have lots of fiber, such as whole grains and fruits. These will promote removal of toxins from the body that interfere with healing.”
Pregunta 4
Pregunta
The nurse is caring for a patient who has undergone skin grafting of the face and arms for burn wound treatment. A primary nursing diagnosis is
Pregunta 5
Pregunta
The nurse is caring for a patient with an electrical injury. The nurse understands that patients with electrical injury are at a high risk for acute kidney injury secondary to
Respuesta
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release of myoglobin from injured tissues.
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increased incidence of ureteral stones.
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hypervolemia from burn resuscitation.
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nephrotoxic antibiotics for prevention of infection
Pregunta 6
Pregunta
A(An) ____________________ often produces a superficial cutaneous injury but may cause cardiopulmonary arrest and transient but severe central nervous system deficits.
Respuesta
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electrical burn
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chemical burn
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infection
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heat burn
Pregunta 7
Pregunta
Silver is used as an ingredient in many burn dressings because it
Respuesta
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stimulates tissue granulation.
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provides topical pain relief.
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is effective against a wide spectrum of wound pathogens.
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stimulates wound healing.
Pregunta 8
Pregunta
A 63-year-old patient is admitted with new-onset fever; flulike symptoms; blisters over the arms, chest, and neck; and red, painful oral mucous membranes. The patient should be further evaluated for which possible non–burn-injured skin disorder?
Respuesta
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Toxic epidermal necrolysis
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Graft-versus-host disease
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Necrotizing soft tissue infection
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Staphylococcal scalded skin syndrome
Pregunta 9
Pregunta
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
Respuesta
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disseminated intravascular coagulation disorder.
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intra-abdominal hypertension.
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acute respiratory distress syndrome.
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acute kidney injury.
Pregunta 10
Pregunta
Tissue damage from burn injury activates an inflammatory response that increases the patient’s risk for
Pregunta 11
Pregunta
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
Pregunta 12
Pregunta
The nurse is managing the pain of a patient with burns. The provider has prescribed opiates to be given intramuscularly. The nurse contacts the provider to change the prescription to intravenous administration because
Respuesta
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burn pain is so severe it requires relief by the fastest route available.
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hypermetabolism limits effectiveness of medications administered intramuscularly.
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tissue edema may interfere with drug absorption of injectable routes.
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intramuscular injections cause additional skin disruption.
Pregunta 13
Pregunta
The nurse is caring for a burn-injured patient who weighs 154 pounds, and the burn injury covers 50% of his body surface area. The nurse calculates the fluid needs for the first 24 hours after a burn injury using a standard fluid resuscitation formula of 4 mL/kg/% burn of intravenous (IV) fluid for the first 24 hours. The nurse plans to administer what amount of fluid in the first 24 hours?
Respuesta
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14 L
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7000 mL
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28 L
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2800 mL
Pregunta 14
Pregunta
In patients with extensive burns, edema occurs in both burned and unburned areas because of
Respuesta
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increased capillary permeability.
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catecholamine-induced vasoconstriction
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decreased glomerular filtration.
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loss of integument barrier
Pregunta 15
Pregunta
Patients with burns may have mesh grafts or sheet grafts. Which of the following sites is most likely to have a sheet graft applied?
Pregunta 16
Pregunta
When paramedics notice 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?
Respuesta
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Inhalation injury above the glottis may cause significant edema that obstructs the airway.
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The singed hairs and soot in the nostrils will cause dysfunction of cilia in the airways
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Carbon monoxide poisoning always occurs when soot is visible.
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The patient will have a copious amount of mucus that will need to be suctioned.
Pregunta 17
Pregunta
The nurse is conducting an admission assessment of an 82-year-old patient who sustained a 12% burn from spilling hot coffee on the hand and arm. Which statement is of priority to assist in planning treatment?
Respuesta
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“Do you live alone?”
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Have you had any surgeries?”
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“Do you have a heart condition or heart failure?”
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“Do you have any drug or food allergies?”
Pregunta 18
Pregunta
The nurse is caring for a patient with a chemical burn injury. The priority nursing intervention is to
Pregunta 19
Pregunta
The patient asks the nurse if the placement of the autograft over his full-thickness burn will be the only surgical intervention needed to close his wound. The nurse’s best response would be:
Respuesta
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“Yes, an autograft will transfer your own skin from one area of your body to cover the burn wound.”
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Unfortunately, an autograft skin is a temporary graft and a second surgery will be needed to close the wound.”
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“An autograft is a biological dressing that will eventually be replaced by your body generating new tissue.”
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“Unfortunately, autografts frequently do not adhere well to burn wounds and a xenograft will be necessary to close the wound.”
Pregunta 20
Pregunta
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 in the water too long.” What should the nurse do?
Respuesta
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Ask the caregiver to step out while examining the patient’s burn injury.
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Immediately contact the police to report the suspected elder abuse.
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Ask the caregiver to describe exactly how the injury occurred.
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Ask the caregiver at what temperature the water heater is set in the home.