Nokea
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.
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A nurse who is taking care of a patient with burns is asked by a family member why the patient is losing so much weight. The patient is currently in the intermediate phase of recovery. What would be the nurses most appropriate response to the family member?
- A. Hes on a calorie-restricted diet in order to divert energy to wound healing.
- B. His body has consumed his fat deposits for fuel because his calorie intake is lower than normal.
- C. He actually hasnt lost weight. Instead, theres been a change in the distribution of his body fat.
- D. He lost many fluids while he was being treated in the emergency phase of burn care.
Correct Answer: B
Rationale: Hypermetabolism in the acute phase causes significant weight loss as the body catabolizes fat reserves, despite increased nutritional support. Calorie restriction is not used, fluid loss is earlier, and fat distribution changes are not typical.
A home care nurse is performing a visit to a patients home to perform wound care following the patients hospital treatment for severe burns. While interacting with the patient, the nurse should assess for evidence of what complication?
- A. Psychosis
- B. Post-traumatic stress disorder
- C. Delirium
- D. Vascular dementia
Correct Answer: B
Rationale: Post-traumatic stress disorder is a common complication in burn survivors, with a high prevalence due to the traumatic nature of the injury. Psychosis, delirium, and dementia are not typical.
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 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 patients burns are estimated at 36% of total body surface area; fluid resuscitation has been ordered in the emergency department. After establishing intravenous access, the nurse should anticipate the administration of what fluid?
- A. 0.45% NaCl with 20 mEq/L KCl
- B. 0.45% NaCl with 40 mEq/L KCl
- C. Normal saline
- D. Lactated Ringers
Correct Answer: D
Rationale: Lactated Ringers is the preferred fluid for burn resuscitation, closely matching plasma osmolality and avoiding hyperchloremic acidosis associated with normal saline. Potassium-containing fluids risk worsening hyperkalemia.