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Which of the following actions should be included in the plan of care for a patient who has burns of the ears, head, neck, and right arm and hand?
- A. Place the right arm and hand flexed in a position of comfort.
- B. Elevate the right arm and hand on pillows and extend the fingers.
- C. Assist the patient to a supine position with a small pillow under the head.
- D. Position the patient in a side-lying position with rolled towel under the neck.
Correct Answer: B
Rationale: The right hand and arm should be elevated to reduce swelling and the fingers extended to avoid flexion contractures (even though this position may not be comfortable for the patient). The patient with burns of the ears should not use a pillow since this will put pressure on the ears and may stick to the ears. Patients with neck burns should not use a pillow, since the head should be maintained in an extended position in order to avoid contractures.
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Which of the following frequencies of multiple-dressing method burn treatment dressing changes should the nurse should question?
- A. Every 6 hours
- B. Every 12 hours
- C. Once a day
- D. Once a week
Correct Answer: A
Rationale: These dressings are changed at various intervals, from every 12 to 24 hours to once every 14 days, depending on the product. However, the dressing should not be changed 6 hours from application.
The nurse is admitting a patient with extensive electrical burn injuries. Which of the following prescribed interventions should the nurse implement first?
- A. Start two large bore IVs.
- B. Place on cardiac monitor.
- C. Apply dressings to burned areas.
- D. Assess for pain at contact points.
Correct Answer: B
Rationale: After an electrical burn, the patient is at risk for fatal dysrhythmias and should be placed on a cardiac monitor. The other actions should be accomplished in the following order: Start two IVs, assess for pain, and apply dressings.
The nurse is caring for a patient with severe burns who is receiving crystalloid fluid replacement IV. ordered using the Parkland formula. The initial volume of fluid to be administered in the first 24 hours is 30000 ml. The initial rate of administration is 1875 ml/hour. Which of the following infusion rates is accurate after the first 8 hours?
- A. 350 ml/hour
- B. 253 ml/hour
- C. 938 ml/hour
- D. 250 ml/hour
Correct Answer: C
Rationale: Half of the fluid replacement using the Parkland formula is administered in the first 8 hours and the other half over the next 16 hours (25% per each 8 hour period, respectively). In this case, the patient should receive half of the initial rate, or 938 ml/hour.
The nurse is caring for a patient who has burns over 30% of the body surface. Which of the following events indicates that the patient has moved from the emergent to the acute phase of the burn injury?
- A. White blood cell levels decrease.
- B. Blisters and edema have subsided
- C. The patient has large quantities of pale urine.
- D. The patient has been hospitalized for 48 hours.
Correct Answer: C
Rationale: At the end of the emergent phase, capillary permeability normalizes and the patient begins to diurese large amounts of urine with a low specific gravity. Although this may occur at about 48 hours, it may be longer in some patients. Blisters and edema begin to resolve, but this process requires more time. White blood cells may increase or decrease, based on the patient's immune status and any infectious processes.
The nurse is estimating the extent of a burn using the rule of nines for a patient who has been admitted with deep partial-thickness burns of the posterior trunk and right arm. What percentage of the patient's total body surface area (TBSA) has been injured?
Correct Answer: 27
Rationale: When using the rule of nines, the posterior trunk is considered to cover 18% of the patient's body and each arm is 9%. Thus, 18% + 9% = 27% TBSA.