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An emergency department nurse has just admitted a patient with a burn. What characteristic of the burn will primarily determine whether the patient experiences a systemic response to this injury?
- A. The length of time since the burn
- B. The location of burned skin surfaces
- C. The source of the burn
- D. The total body surface area (TBSA) affected by the burn
Correct Answer: D
Rationale: TBSA is the primary determinant of systemic response, as larger burns cause greater fluid loss, metabolic demand, and organ stress. Time, location, and source are secondary factors.
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The nurse is preparing the patient for mechanical debridement and informs the patient that this will involve which of the following procedures?
- A. A spontaneous separation of dead tissue from the viable tissue
- B. Removal of eschar until the point of pain and bleeding occurs
- C. Shaving of burned skin layers until bleeding, viable tissue is revealed
- D. Early closure of the wound
Correct Answer: B
Rationale: Mechanical debridement involves manually removing eschar with tools like scissors or forceps until pain and bleeding indicate viable tissue. Spontaneous separation is natural debridement, shaving is surgical, and early closure is not debridement.
An emergency department nurse has just received a patient with burn injuries brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the patients body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period?
- A. Administer IV fluids
- B. Administer broad-spectrum antibiotics
- C. Administer IV potassium chloride
- D. Administer packed red blood cells
Correct Answer: A
Rationale: IV fluid administration is critical to address massive fluid losses and prevent hypovolemic shock in the initial burn-shock period. Antibiotics, potassium, or PRBCs are not immediate priorities.
A patient in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the patients laboratory studies, the nurse will expect the results to indicate what?
- A. Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis
- B. Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis
- C. Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis
- D. Hypokalemia, hyponatremia, elevated hematocrit, and metabolic alkalosis
Correct Answer: A
Rationale: In the emergent phase, cell damage releases potassium (hyperkalemia), sodium is lost to edema (hyponatremia), hemoconcentration increases hematocrit, and tissue hypoxia causes metabolic acidosis. Other combinations do not align with burn pathophysiology.
While performing a patients ordered wound care for the treatment of a burn, the patient has made a series of sarcastic remarks to the nurse and criticized her technique. How should the nurse best interpret this patients behavior?
- A. The patient may be experiencing an adverse drug reaction that is affecting his cognition and behavior.
- B. The patient may be experiencing neurologic or psychiatric complications of his injuries.
- C. The patient may be experiencing inconsistencies in the care that he is being provided.
- D. The patient may be experiencing anger about his circumstances that he is deflecting toward the nurse.
Correct Answer: D
Rationale: Anger is common in burn patients and may be deflected toward caregivers. Drug reactions, complications, or care inconsistencies are less likely without specific evidence.
An occupational health nurse is called to the floor of a factory where a worker has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to cool the burn. How should the nurse cool the burn?
- A. Apply ice to the site of the burn for 5 to 10 minutes.
- B. Wrap the patients affected extremity in ice until help arrives.
- C. Apply an oil-based substance or butter to the burned area until help arrives.
- D. Wrap cool towels around the affected extremity intermittently.
Correct Answer: D
Rationale: Cool towels or water applied intermittently relieve pain and limit tissue damage without causing hypothermia, which ice can induce. Oil-based substances like butter trap heat, worsening the burn.