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An emergency department nurse learns from the paramedics that they are transporting a patient who has suffered injury from a scald from a hot kettle. What variables will the nurse consider when determining the depth of burn?
- A. The causative agent
- B. The patients preinjury health status
- C. The patients prognosis for recovery
- D. The circumstances of the accident
Correct Answer: A
Rationale: Burn depth is determined by factors like the causative agent (e.g., scalding liquid), temperature, contact duration, and skin thickness. Preinjury health, prognosis, and accident circumstances are not direct determinants.
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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.
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.
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 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 arrives in the emergency department after being burned in a house fire. The patients burns cover the face and the left forearm. What extent of burns does the patient most likely have?
- A. 13%
- B. 25%
- C. 9%
- D. 18%
Correct Answer: D
Rationale: Using the Rule of Nines, the face accounts for 9% and the left forearm 9%, totaling 18% TBSA.