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A nurse on a burn unit is caring for a patient in the acute phase of burn care. While performing an assessment during this phase of burn care, the nurse recognizes that airway obstruction related to upper airway edema may occur up to how long after the burn injury?
- A. 2 days
- B. 3 days
- C. 5 days
- D. 1 week
Correct Answer: A
Rationale: Upper airway edema from burns can develop up to 48 hours post-injury due to inflammation and fluid shifts, requiring vigilant monitoring. Later onset is less likely.
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A burn patient is transitioning from the acute phase of the injury to the rehabilitation phase. The patient tells the nurse, I cant wait to have surgery to reconstruct my face so I look normal again. What would be the nurses best response?
- A. Thats something that you and your doctor will likely talk about after your scars mature.
- B. That is something for you to talk to your doctor about because its not a nursing responsibility.
- C. I know this is really important to you, but you have to realize that no one can make you look like you used to.
- D. Unfortunately, its likely that you will have most of these scars for the rest of your life.
Correct Answer: A
Rationale: Reconstructive surgery is considered after scars mature, typically within 1-2 years, making this an appropriate, hopeful response. Other options dismiss the patient's concern or lack empathy.
A patient with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the patient closely for what signs of the onset of burn shock?
- A. Confusion
- B. High fever
- C. Decreased blood pressure
- D. Sudden agitation
Correct Answer: C
Rationale: Decreased blood pressure signals burn shock onset due to reduced vascular volume from fluid loss. Confusion, fever, or agitation are not primary indicators.
A patient has sustained a severe burn injury and is thought to have an impaired intestinal mucosal barrier. Since this patient is considered at an increased risk for infection, what intervention will best assist in avoiding increased intestinal permeability and prevent early endotoxin translocation?
- A. Early enteral feeding
- B. Administration of prophylactic antibiotics
- C. Bowel cleansing procedures
- D. Administration of stool softeners
Correct Answer: A
Rationale: Early enteral feeding supports the intestinal mucosal barrier, reducing permeability and preventing endotoxin translocation. Prophylactic antibiotics risk resistant bacteria, and bowel cleansing or stool softeners do not address this issue.
A nurse is developing a care plan for a patient with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. What is the best rationale for this intervention?
- A. To prevent neuropathies
- B. To prevent wound breakdown
- C. To prevent contractures
- D. To prevent heterotopic ossification
Correct Answer: C
Rationale: Maintaining joint alignment prevents contractures, a common complication of burns due to tissue shortening. It does not primarily prevent neuropathies, wound breakdown, or ossification.
A patient has experienced burns to his upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action?
- A. Instruct the patient to keep the wound site in a dependent position.
- B. Administer PRN analgesia as ordered.
- C. Assess the patients peripheral pulses distal to the dressing.
- D. Assist with passive range of motion exercises to set the new dressing.
Correct Answer: C
Rationale: Checking peripheral pulses ensures dressings are not too tight, preventing circulatory compromise. Dependent positioning is avoided, analgesia is given before dressing changes, and ROM exercises are not typically post-dressing.