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A nurse has reported for a shift at a busy burns and plastics unit in a large university hospital. Which patient is most likely to have life-threatening complications?
- A. A 4-year-old scald victim burned over 24% of the body
- B. A 27-year-old male burned over 36% of his body in a car accident
- C. A 39-year-old female patient burned over 18% of her body
- D. A 60-year-old male burned over 16% of his body in a brush fire
Correct Answer: A
Rationale: Young children, like the 4-year-old, have higher morbidity and mortality risk due to physiological immaturity, making their burns more life-threatening despite smaller TBSA compared to adults.
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A patient experienced a 33% TBSA burn 72 hours ago. The nurse observes that the patients hourly urine output has been steadily increasing over the past 24 hours. How should the nurse best respond to this finding?
- A. Obtain an order to reduce the rate of the patients IV fluid infusion.
- B. Report the patients early signs of acute kidney injury (AKI).
- C. Recognize that the patient is experiencing an expected onset of diuresis.
- D. Administer sodium chloride as ordered to compensate for this fluid loss.
Correct Answer: C
Rationale: Increased urine output 72 hours post-burn indicates the onset of diuresis as capillaries regain integrity, shifting fluid back to the intravascular space. This is expected, not indicative of AKI or requiring fluid reduction or sodium administration.
A patient with a partial-thickness burn injury had Biobrane applied 2 weeks ago. The nurse notices that the Biobrane is separating from the burn wound. What is the nurses most appropriate intervention?
- A. Reinforce the Biobrane dressing with another piece of Biobrane.
- B. Remove the Biobrane dressing and apply a new dressing.
- C. Trim away the separated Biobrane.
- D. Notify the physician for further emergency-related orders.
Correct Answer: C
Rationale: As Biobrane separates naturally from a healing wound, trimming the loose edges is appropriate, leaving the adhered portion intact. Reinforcing, replacing, or notifying the physician is unnecessary.
A nurse is caring for a patient who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis?
- A. Activity Intolerance
- B. Anxiety
- C. Ineffective Coping
- D. Acute Pain
Correct Answer: D
Rationale: Acute pain is a priority in deep partial-thickness burns due to its severity, impacting recovery and contributing to anxiety or coping issues. Pain management often precedes addressing other diagnoses.
A patient has experienced an electrical burn and has developed thick eschar over the burn site. Which of the following topical antibacterial agents will the nurse expect the physician to order for the wound?
- A. Silver sulfadiazine 1% (Silvadene) water-soluble cream
- B. Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream
- C. Silver nitrate 0.5% aqueous solution
- D. Acticoat
Correct Answer: B
Rationale: Mafenide acetate penetrates thick eschar, making it ideal for electrical burns with deep tissue involvement. Silver sulfadiazine and silver nitrate do not penetrate eschar effectively, and Acticoat is a dressing, not a topical agent.
A patient is brought to the ED by paramedics, who report that the patient has partial-thickness burns on the chest and legs. The patient has also suffered smoke inhalation. What is the priority in the care of a patient who has been burned and suffered smoke inhalation?
- A. Pain
- B. Fluid balance
- C. Anxiety and fear
- D. Airway management
Correct Answer: D
Rationale: Airway management is the priority due to the risk of obstruction from smoke inhalation-induced edema, following the ABCs of trauma care. Pain, fluid balance, and anxiety are secondary.