1. Answer: D.

Rationale: According to the rule of nines, with the initial burn, the anterior half of the head equals 4.5%, the upper half of the anterior torso equals 9%, and the lower half of both arms equals 9%. The subsequent burn included the posterior half of the head, equaling 4.5%, and the upper half of the posterior torso, equaling 9%. This totals 36%.

  1. Answer: A.

Rationale: Escharotomies are performed to relieve the compartment syndrome that can occur when edema forms under non-distensible eschar in a circumferential third-degree burn. The escharotomy releases the tourniquet-like compression around the arm. Escharotomies are performed through avascular eschar to subcutaneous fat. Although bleeding may occur from the site, it is considered a complication rather than an anticipated therapeutic outcome. Usually, direct pressure with a bulky dressing and elevation control the bleeding, but occasionally an artery is damaged and may require ligation. Escharotomy does not affect the formation of edema. The formation of granulation tissue is not the intent of an escharotomy.

  1. Answer: C.

Rationale: Fluid management during the first 24 hours following a burn injury generally includes the infusion of (usually) lactated Ringer’s solution. Lactated Ringer’s solution is an isotonic solution that contains electrolytes that will maintain fluid volume in the circulation. Fluid resuscitation is determined by urine output, and hourly urine output should be at least 30 mL/hour. The client’s urine output is indicative of insufficient fluid resuscitation, which places the client at risk for inadequate perfusion of the brain, heart, kidneys, and other body organs. Therefore, the HCP would prescribe an increase in the amount of IV lactated Ringer’s solution administered per hour. There is nothing in the situation that calls for blood replacement, which is not used for fluid therapy for burn injuries. Administering a diuretic would not correct the problem because fluid replacement is needed. Diuretics promote the removal of the circulating volume, thereby further compromising the inadequate tissue perfusion. Intravenous 5% dextrose solution is isotonic before administered but is hypotonic once the dextrose is metabolized. Hypotonic solutions are not appropriate for fluid resuscitation of a client with significant burn injuries.

  1. Answer: B, C, E

Rationale: The primary goal for a burn injury is to maintain a patent airway, administer intravenous (IV) fluids to prevent hypovolemic shock, and preserve vital organ functioning. Therefore, the priority actions are to assess for airway patency and maintain a patent airway. The nurse then prepares to administer oxygen. Oxygen is necessary to perfuse vital tissues and organs. An IV line should be obtained, and fluid resuscitation started. The extremities are elevated to assist in preventing shock and decrease fluid moving to the extremities, especially in the burn-injured upper extremities. The client is kept warm since the loss of skin integrity causes heat loss. The client is placed on NPO (nothing by mouth) status because of the altered gastrointestinal function that occurs as a result of a burn injury.

  1. Answer: D.

Rationale: The resuscitation/emergent phase begins at the time of injury and ends with the restoration of capillary permeability, usually at 48 to 72 hours following the injury. During the resuscitation/emergent phase, the hematocrit level increases to above normal because of hemoconcentration from the large fluid shifts. Hematocrit levels of 50% to 55% (0.50 to 0.55) are expected during the first 24 hours after injury, returning to normal by 36 hours after injury. Initially, blood is shunted away from the kidneys, and renal perfusion and glomerular filtration decrease, resulting in low urine output. The burned client is prone to hypovolemia, and the body attempts to compensate by increased pulse rate and lowered blood pressure. Pulse rates are typically higher than normal, and the blood pressure is decreased due to the large fluid shifts.

  1. Answer: D.

Rationale: If an inhalation injury is suspected, administration of 100% oxygen via a tight-fitting nonrebreather face mask is prescribed until carboxyhemoglobin levels fall (usually below 15%). In inhalation injuries, the oropharynx is inspected for evidence of erythema, blisters, or ulcerations. The need for endotracheal intubation also is assessed. Administration of oxygen by aerosol mask and cannula is incorrect and would not provide the necessary oxygen supply needed for adequate tissue perfusion for the client with a likely inhalation injury.

  1. Answer: B.

Rationale: Successful or adequate fluid resuscitation in the client is signaled by stable vital signs, adequate urine output, palpable peripheral pulses, and clear sensorium. However, the most reliable indicator for determining the adequacy of fluid resuscitation, especially in a client with burns, is the urine output. For an adult, the hourly urine volume should be 30 to 50 mL.

  1. Answer: C.

Rationale: The acute or intermediate phase of burn care follows the emergent/resuscitative phase and begins 48 to 72 hours after the burn injury. During this phase, attention is directed toward continued assessment and maintenance of respiratory and circulatory status, fluid and electrolyte balance, and gastrointestinal function. Infection prevention, burn wound care (i.e., wound cleaning, topical antibacterial therapy, wound dressing, dressing changes, wound debridement, and wound grafting), pain management, and nutritional support are priorities at this stage and are discussed in detail in the following sections. Priorities during the emergent or immediate resuscitative phase include first aid, prevention of shock and respiratory distress, detection and treatment of concomitant injuries, and initial wound assessment and care. The priorities during the rehabilitation phase include prevention of scars and contractures, rehabilitation, functional and cosmetic reconstruction, and psychosocial counseling.

  1. Answer: D.

 Rationale: Fluid and electrolyte changes in the emergent/resuscitative phase of a burn injury include hyperkalemia related to the release of potassium into the extracellular fluid, hyponatremia from a large amount of sodium lost in trapped edema fluid, hemoconcentration that leads to an increased hematocrit, and loss of bicarbonate ions that result in metabolic acidosis.

  1. Answer: B.

Rationale: Mafenide acetate 10% hydrophilic-based cream is
the agent of choice for electrical burns because of its ability to penetrate thick eschar.

  1. Answer: A.

Rationale: During the early phase of burn care, the nurse is most concerned with fluid resuscitation to correct large-volume fluid loss through the damaged skin. Infection, body image, and pain are significant areas of concern but are less urgent than fluid status.

  1. Answer: C

Rationale: As the Biobrane gradually separates, it is trimmed, leaving a healed wound. When the Biobrane dressing adheres to the wound, the wound remains stable and the Biobrane can remain in place for 3 to 4 weeks. You would not reinforce the Biobrane, or remove it and apply a new dressing. Nor would you notify the physician for further orders.

 

  1. Answer: A

Rationale: The following factors are considered in determining the depth of a burn: how the injury occurred, causative agent (such as flame or scalding liquid), the temperature of the burning agent, duration of contact with the agent, and thickness of the skin. To determine the depth of the burn, you do not take into consideration your visual observation of the burned area, how much of the body is burned, or the circumstances of the accident.

  1. Answer: D

Rationale: Systemic threats from a burn are the greatest threat to life. The ABCs of all trauma care apply during the early postburn period. While all options should be addressed, pain, fluid balance, anxiety, and fear do not take precedence over airway management.

  1. Answer: A

Rationale: Anticipated fluid and electrolyte changes that occur during the emergent/resuscitative phase of burn injury include potassium excess, sodium deficit, base-bicarbonate deficit, and elevated hematocrit.

  1. Answer: B

Rationale: Patients lose a great deal of weight during recovery from severe burns. Reserve fat deposits are catabolized, fluids are lost, and caloric intake may be limited.

  1. Answer: A, B, C

Rationale: The severity of each burn injury is determined by multiple factors that, when assessed, help the burn team estimate the likelihood that a patient will survive and plan the care for each patient. These factors include the age of the patient; depth of the burn; the amount of surface area of the body that is burned; the presence of inhalation injury; the presence of other injuries; location of the injury in special care areas such as the face, perineum, hands, and feet; and presence of past medical history. Options D and E are not factors that bear on the severity of the injury.

  1. Answer: B

Rationale: Prompt fluid resuscitation maintains the blood pressure in the low-normal range and improves cardiac output. Despite adequate fluid resuscitation, cardiac filling pressures (central venous pressure, pulmonary artery pressure, and pulmonary artery wedge pressure) remain low during the burn-shock period. If inadequate fluid resuscitation occurs, distributive shock occurs.

  1. Answer: D

Rationale: In a superficial burn, there is a loss of capillary integrity, and fluid is localized to the burn itself, resulting in blister formation and edema only in the area of injury. Capillary refill should be 3 seconds or less. Options B and C are distracters for this question.

  1. Answer: A

Rationale: As edema increases, pressure on small blood vessels and nerves in the distal extremities causes an obstruction of blood flow and consequent ischemia. This complication is similar to compartment syndrome. The physician may need to perform an escharotomy, a surgical incision into the eschar (devitalized tissue resulting from a burn), to relieve the constricting effect of the burned tissue.

  1. Answer: C, D, E

Rationale: Cautious administration of fluids and electrolytes continues during this phase of burn care because of the shifts in fluid from the interstitial to the intravascular compartment, losses of fluid from large burn wounds, and the patient’s physiologic responses to the burn injury.

  1. Answer: B

Rationale: The nurse is responsible for providing a clean and safe environment and closely scrutinizing the burn wound to detect early signs of infection. Visitors are not restricted to a burn patients. The nurse does not clean the patient’s room. The patient is maintained in a clean environment, not a sterile environment.

  1. Answer: D

Rationale: Prevention of deep vein thrombosis (DVT) is an important factor in care. Early mobilization of the patient is important. The nurse monitors the splints and functional devices but does not maintain them. The nurse does not maintain a discussion with a psychologist about the patient.

  1. Answer: D

Rationale: Inhalation injury results in exposure of the respiratory tract to intense heat or flames with inhalation of noxious chemicals, smoke, or carbon monoxide. The nurse should anticipate the need for intubation and mechanical ventilation because this patient is demonstrating signs of severe respiratory distress.

  1. Answer: B

Rationale:  Infection is the most serious threat concerning further tissue injury and possible sepsis.

  1. Answer: C

Rationale: Recovery from a burn injury to 30% of total body surface area (TBSA) takes time and is exhausting, both physically and emotionally, for the patient. The health care team may think that a patient is ready for discharge, but the patient may not know that discharge is being contemplated in the near future. Patients are often very fearful about how they will manage at home. The patient would benefit from the nurse’s careful review of his or her progress and readiness for discharge; then, the nurse should outline the plans for support and follow-up after discharge.

  1. Answer: B

Rationale: Fluid resuscitation with the Parkland (Baxter) formula recommends that one half of the total fluid requirement should be administered in the first 8 hours, one-quarter of total fluid requirement should be administered in the second 8 hours, and one-quarter of total fluid requirement should be administered in the third 8 hours.

 

  1. Answer: A, C, D, E

Rationale: An escharotomy (a scalpel incision through full-thickness eschar) is frequently required to restore circulation to compromised extremities. Daily cleansing and debridement and the application of an antimicrobial ointment are expected interventions used to minimize infection and enhance wound healing. Pain control is essential in the care of a patient with a burn injury. With full-thickness burns, myoglobin and hemoglobin released into the bloodstream can occlude renal tubules. Adequate fluid replacement is used to prevent this occlusion.

  1. Answer: B, C

Rationale: Active and passive ROM maintains the function of body parts and reassures the patient that movement is still possible are the explanations that should be used. Contractures are prevented with ROM as well as splints. Movement facilitates the mobilization of fluid in interstitial fluid back into the vascular bed. Although it is good to collaborate with physical therapy to perform ROM during dressing changes because the patient has already taken analgesics, ROM can and should be done throughout the day.

  1. Answer: C

Rationale: This patient is most likely experiencing hyperosmolar hyperglycemic syndrome (HHS). HHS dehydrates a patient rapidly. Thus HHS combined with the massive fluid losses of a burn tremendously increase this patient’s risk for hypovolemic shock and serious hypotension. This is clearly the nurse’s priority because the nurse must keep up with the patient’s fluid requirements to prevent circulatory collapse caused by low intravascular volume. There is no mention of blood loss. Fluid resuscitation will help to correct the pH and serum potassium abnormalities.

 

References 

  1. Hinkle, J.L. & Cheever, K.H. (2018). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (14th ed.). Philadelphia: Wolters Kluwer.
  2. Ignatavicius, D.D., Workman, M.L., & Rebar, C.R. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care (9th ed.). St. Louis: Elsevier.
  3. Potter, P.A., Perry, A.G., Stockert, P.A., & Hall, A.M. (2019). Essentials for Nursing Practice (9th ed.). St. Louis: Elsevier.
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Nhiña Sandeep de Rosas, MAN, DIH, DSHRM, RN currently works for the Department of Health CHD Mimaropa as a Training Specialist. She is also a Nurse Licensure Exam and NCLEX-RN reviewer on her free time. She has her USRN licenses in New York and Vermont, having passed the NCLEX-RN in 2007.Since 2006, she has been a nurse educator and worked as a clinical instructor and classroom lecturer for Unciano Colleges (College of Nursing) in Antipolo City. She has earned her Master’s Degree in Nursing and Diploma in International Health at the University of the Philippines Open University; and her Diploma in Strategic Human Resource Management at the Ateneo de Manila University.

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