FULL-TEXT: Burns & Burn Injury (100 Questions)

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Burns NCLEX Question and Burn Injury Nursing Management Quiz #4 (20 Items)

NURSESLABS-BURNINJURY-04-001

The newly admitted client has burns on both legs. The burned areas appear white and leather-like. No blisters or bleeding are present, and the client states that he or she has little pain. How should this injury be categorized?

  • A. Superficial
  • B. Partial-thickness superficial
  • C. Partial-thickness deep
  • D. Full thickness

Correct Answer: D. Full thickness

The characteristics of the wound meet the criteria for a full-thickness injury (color that is black, brown, yellow, white, or red; no blisters; pain minimal; outer layer firm and inelastic). With pressure, no blanching occurs. The burn is leathery and dry. There is minimal to no pain because of decreased sensation. Full-thickness burns heal by contracture and take greater than 8 weeks. Full-thickness burns require skin grafting.

  • Option A: Superficial (first-degree) involves the epidermis of the skin only. It appears pink to red, there are no blisters, and it is dry. It is moderately painful. Superficial burns heal without scarring within 5 to 10 days.
  • Option B: Superficial partial-thickness (second-degree) involves the superficial dermis. It appears red with blisters and is wet. The erythema blanches with pressure. The pain associated with superficial partial-thickness is severe. Healing typically occurs within 3 weeks with minimal scarring.
  • Option C: Deep partial-thickness (second-degree) involves the deeper dermis. It appears yellow or white, is dry, and does not blanch with pressure. There is minimal pain due to a decreased sensation. Healing occurs in 3 to 8 weeks with scarring present.

NURSESLABS-BURNINJURY-04-002

The newly admitted client has a large burned area on the right arm. The burned area appears red, has blisters, and is very painful. How should this injury be categorized?

  • A. Superficial
  • B. Partial-thickness superficial
  • C. Partial-thickness deep
  • D. Full thickness

Correct Answer: B. Partial-thickness superficial

The characteristics of the wound meet the criteria for a superficial partial-thickness injury (color that is pink or red; blisters; pain present and high). Superficial partial-thickness (second-degree) involves the superficial dermis. It appears red with blisters and is wet. The erythema blanches with pressure. The pain associated with superficial partial-thickness is severe. Healing typically occurs within 3 weeks with minimal scarring.

  • Option A: Superficial (first-degree) involves the epidermis of the skin only. It appears pink to red, there are no blisters, and it is dry. It is moderately painful. Superficial burns heal without scarring within 5 to 10 days.
  • Option C: Deep partial-thickness (second-degree) involves the deeper dermis. It appears yellow or white, is dry, and does not blanch with pressure. There is minimal pain due to a decreased sensation. Healing occurs in 3 to 8 weeks with scarring present.
  • Option D: Third-degree involves the full thickness of skin and subcutaneous structures. It appears white or black/brown. With pressure, no blanching occurs. The burn is leathery and dry. There is minimal to no pain because of decreased sensation. Full-thickness burns heal by contracture and take greater than 8 weeks. Full-thickness burns require skin grafting.

NURSESLABS-BURNINJURY-04-003

The burned client newly arrived from an accident scene is prescribed to receive 4 mg of morphine sulfate by IV push. What is the most important reason to administer the opioid analgesic to this client by the intravenous route?

  • A. The medication will be effective more quickly than if given intramuscularly.
  • B. It is less likely to interfere with the client’s breathing and oxygenation.
  • C. The danger of an overdose during fluid remobilization is reduced.
  • D. The client delayed gastric emptying.

Correct Answer: C. The danger of an overdose during fluid remobilization is reduced.

The most important reason is to prevent an overdose from accumulation of drug in the interstitial space during the fluid shift of the emergent phase. When edema is present, cumulative doses are rapidly absorbed when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics.

  • Option A: Providing some pain relief has a high priority and giving the drug by the IV route instead of IM, SC, or orally does increase the rate of effect. Pain that is more severe and not well controlled may be manageable with single or continuous doses of IV, epidural, and intrathecal formulations. Infusion dosing can vary significantly between patients and largely depends on how naive or tolerant they are to opiates.
  • Option B: Respiratory depression is among the more serious adverse reactions with opiate use that is especially important to monitor in the postoperative patient population. Extreme caution is necessary with severe respiratory depression and asthma exacerbation cases since morphine can further decrease the respiratory drive.
  • Option D: Delayed gastric emptying is not a side effect of morphine. Among the more common unwanted effects of morphine use is constipation. This effect occurs via stimulation of mu-opioid receptors on the myenteric plexus, which in turn inhibits gastric emptying and reduces peristalsis.

NURSESLABS-BURNINJURY-04-004

Which vitamin deficiency is most likely to be a long-term consequence of a full-thickness burn injury?

  • A. Vitamin A
  • B. Vitamin B
  • C. Vitamin C
  • D. Vitamin D

Correct Answer: D. Vitamin D

Skin exposed to sunlight activates vitamin D. Partial-thickness burns reduce the activation of vitamin D. Activation of vitamin D is lost completely in full-thickness burns. The loss of healthy skin following a burn injury can decrease epidermal vitamin D production. Additionally, low vitamin D levels have been reported to have continued for 7 years post-burn in pediatric outpatients.

  • Option A: Vitamin A deficiency (VAD) is a highly prevalent health concern associated with substantial morbidity and mortality, mostly affecting young children in impoverished regions throughout the world. Insufficient intake of absorption leads to deficiency and compromise of essential physiologic processes.
  • Option B: Vitamin B12 deficiency can lead to hematologic and neurological symptoms. Vitamin B12 is stored in excess in the liver, decreasing the likelihood of deficiency. However, in cases in which vitamin B12 cannot be absorbed, for example, due to dietary insufficiency, malabsorption, or lack of intrinsic factor, hepatic stores are depleted, and deficiency ensues.
  • Option C: Vitamin C deficiency, also known as scurvy, is a disease primarily associated with socioeconomic status and access to food. Signs and symptoms are often readily visible in individuals who develop this disease. The classic constellation of corkscrew hairs, perifollicular hemorrhage, and gingival bleeding is highly suggestive of vitamin C deficiency.

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NURSESLABS-BURNINJURY-04-005

Which client factors should alert the nurse to potential increased complications with a burn injury?

  • A. The client is a 26-year-old male.
  • B. The client has had a burn injury in the past.
  • C. The burned areas include the hands and perineum.
  • D. The burn took place in an open field and ignited the client’s clothing.

Correct Answer: C. The burned areas include the hands and perineum.

Burns of the perineum increase the risk for sepsis. Burns of the hands require special attention to ensure the best functional outcome. Complications are related to the extension of the burn. Burns to the genitalia and perineum are severe conditions that all urologists should be familiar with and know how to manage. Fluid resuscitation is the initial step in treating these patients and is followed by topical dressings in the case of superficial burns.

  • Option A: Irrespective of the type of burn injury, the aged population shows slower recoveries and suffers more complications. Age-associated immune dysfunction, immunosenescence, may predispose the elderly burn patients to more infections, slower healing, and/or to other complications.
  • Option B: Accordingly, patients with burn injury cannot be considered recovered when the wounds have healed; instead, burn injury leads to long-term profound alterations that must be addressed to optimize quality of life.
  • Option D: Burns to the genitals correspond to approximately 2% of all burn patients in North American case series. The majority of those cases are associated with greater burned body surface areas, in which direct fire and scalding are the most frequent causes. Burn management begins with opportune diagnosis and entails making the correct classification, depending on the depth of the lesion.

NURSESLABS-BURNINJURY-04-006

The burned client is ordered to receive intravenous cimetidine, an H2 histamine blocking agent, during the emergent phase. When the client’s family asks why this drug is being given, what is the nurse’s best response?

  • A. “To increase urine output and prevent kidney damage.”
  • B. “To stimulate intestinal movement and prevent abdominal bloating.”
  • C. “To decrease hydrochloric acid production in the stomach and prevent ulcers.”
  • D. “To inhibit loss of fluid from the circulatory system and prevent hypovolemic shock.”

Correct Answer: C. “To decrease hydrochloric acid production in the stomach and prevent ulcers.”

Ulcerative gastrointestinal disease may develop within 24 hours after a severe burn as a result of increased hydrochloric acid production and decreased mucosal barrier. Cimetidine inhibits the production and release of hydrochloric acid.

  • Option A: Adequate fluid therapy is crucial in maintaining renal function. Monitoring by urine output or Swan-Ganz catheterization and thermodilution cardiac output determination is useful in the circulatory management of severely burned patients. Albumin infusion increases plasma volume by 37% and normalizes elevated basal levels of aldosterone and plasma renin activity.
  • Option B: Other management for severe burns includes nasogastric tube placement as most patients will develop ileus. Foley catheters should be placed to monitor urine output. Cardiac and pulse oximetry monitoring are indicated.  Pain control is best managed with IV medication.
  • Option D: Patients with burns of more than 20% – 25% of their body surface should be managed with aggressive IV fluid resuscitation to prevent “burn shock.” A variety of formulas exist, like Brooke, Galveston, Rule of Ten, etc.4, but the most common formula is the Parkland Formula. This formula estimates the amount of fluid given in the first 24 hours, starting from the time of the burn.

NURSESLABS-BURNINJURY-04-007

At what point after a burn injury should the nurse be most alert for the complication of hypokalemia?

  • A. Immediately following the injury
  • B. During the fluid shift
  • C. During fluid remobilization
  • D. During the late acute phase

Correct Answer: C. During fluid remobilization

Hypokalemia is most likely to occur during the fluid remobilization period as a result of dilution, potassium movement back into the cells, and increased potassium excreted into the urine with the greatly increased urine output. In an attempt to prevent hypokalemia it is advised to add ’20-30 mEq/1 of potassium to the hypotonic fluids in order to compensate for urinary losses and intracellular shift; it is also mandatory to correct precipitating factors such as increased pH, hypomagnesemia, and several drugs.

  • Option A: In major burns. intravascular volume is lost in burned and unburned tissues: this process is due to an increase in vascular permeability, increased interstitial osmotic pressure in burn tissue. and cellular edema. with the most significant shifts occurring in the first hours. Hyponatremia is frequent, and the restoration of sodium losses in the burn tissue is, therefore, essential hyperkalemia is also characteristic of this period because of the massive tissue necrosis.
  • Option B: The early post-resuscitation phase is a period of transition from the shock phase to the hypermetabolic phase, and fluid strategies should change radically with a view to restoring losses due to water evaporation. The main changes in this period are hypernatremia, hypocalcemia, hypokalemia, hypomagnesemia, and hypophosphatemia.
  • Option D: The acute phase of burns is defined as a period extending from the onset of burns with shock to the time taken for wound epithelialization which normally takes about 12 to 14 days if management of burns is adequate.

NURSESLABS-BURNINJURY-04-008

What clinical manifestation should alert the nurse to possible carbon monoxide poisoning in a client who experienced a burn injury during a house fire?

  • A. Pulse oximetry reading of 80%
  • B. Expiratory stridor and nasal flaring
  • C. Cherry red color to the mucous membranes
  • D. Presence of carbonaceous particles in the sputum

Correct Answer: C. Cherry red color to the mucous membranes

The saturation of hemoglobin molecules with carbon monoxide and the subsequent vasodilation induces a “cherry red” color of the mucous membranes in these clients. Cherry-red skin color associated with severe carbon monoxide poisoning is seen in only 2-3% of symptomatic cases. Skin may develop erythematous lesions and bulla, especially over bony prominences.

  • Option A: Carbon monoxide quickly binds with hemoglobin with an affinity greater than that of oxygen to form COHb. The resulting decrease in arterial oxygen content and shift of the oxyhemoglobin dissociation curve to the left explains the acute hypoxic symptoms (primarily neurologic and cardiac) seen in patients with acute poisoning.
  • Option B: Patients suffering from smoke inhalation may have symptoms of burning sensation in the nose or throat (which is often caused by an irritant chemical toxin), a cough with increased sputum production, stridor, and dyspnea with rhonchi or wheezing.
  • Option D: The other manifestations are associated with inhalation injury, but not specifically carbon monoxide poisoning. Physical examination should include looking for facial burns, such as loss of facial and intranasal hair as well as carbonaceous material or soot in the mouth or sputum.

NURSESLABS-BURNINJURY-04-009

What clinical manifestation indicates that an escharotomy is needed on a circumferential extremity burn?

  • A. The burn is full thickness rather than partial thickness.
  • B. The client is unable to fully pronate and supinate the extremity.
  • C. Capillary refill is slow in the digits and the distal pulse is absent.
  • D. The client cannot distinguish the sensation of sharp versus dull in the extremity.

Correct Answer: C. Capillary refill is slow in the digits and the distal pulse is absent.

Circumferential eschar can act as a tourniquet when edema forms from the fluid shift, increasing tissue pressure, and preventing blood flow to the distal extremities, and increasing the risk for tissue necrosis. This problem is an emergency and, without intervention, can lead to loss of the distal limb. This problem can be reduced or corrected with an escharotomy.

  • Option A: The American Burn Association recommends burn center referrals for patients with full-thickness burns. Patients being transferred to burn centers do not need extensive debridement or topical antibiotics before transfer.
  • Option B: Once established, burn contractures can be treated with serial splinting, release of contracting bands with Z-plasties, incision, and skin grafting or excision, and resurfacing with skin grafts or flaps, local rotation flaps, use of tissue expanders, or with free flap reconstruction.
  • Option D: After a deep burn injury, cutaneous nerve regeneration will occur with the migration of new nerve fibers from the wound bed or from the collateral sprouting of nerve fibers from adjacent uninjured areas. This nerve regeneration process is imperfect. It was reported that 71% of extensively burned victims suffer from abnormal sensations and 36% from chronic pain. Recent studies on rats have shown that vagus nerve stimulation improved thermal injury-induced shock symptoms.

NURSESLABS-BURNINJURY-04-010

What additional laboratory test should be performed on any African American client who sustains a serious burn injury?

  • A. Total protein
  • B. Tissue type antigens
  • C. Prostate-specific antigen
  • D. Hemoglobin S electrophoresis

Correct Answer: D. Hemoglobin S electrophoresis

Sickle cell disease and sickle cell trait are more common among African Americans. Although clients with sickle cell disease usually know their status, the client with sickle cell trait may not. The fluid, circulatory, and respiratory alterations that occur in the emergent phase of a burn injury could result in decreased tissue perfusion that is sufficient to cause sickling of cells, even in a person who only has the trait. Determining the client’s sickle cell status by checking the percentage of hemoglobin S is essential for any African American client who has a burn injury.

  • Option A: Burn patients can also have important reduction in albumin level due to a higher vascular permeability in the burn wounds that produces exudation with an important protein loss through the burn wound and acute phase response of plasma protein synthesis in liver that occurs with even a very small percentage of burn skin (0.8%) and that produces a decrease to about 80% of normal albumin and prealbumin levels.
  • Option B: Immunochemical studies of the sera of patients with severe burns led to the conclusion that as soon as within the first two days following the trauma, tissue antigens sharing common components with those of the burned and normal skin were detected in the blood. The antigens in question were not detected in the sera of healthy subjects and were not identical with the C-reactive protein. Long-term circulation of these antigens, i.e. for 2 to 3 months after burning, was revealed.
  • Option C: For the detection of prostate cancer, an elevated serum prostate-specific antigen is the most common laboratory abnormality, as the majority of men with early prostate cancer have no symptoms. However, prostate-specific antigen, otherwise known as PSA, is clinically imprecise as benign and malignant processes both can elevate the serum marker.

NURSESLABS-BURNINJURY-04-011

Which type of fluid should the nurse expect to prepare and administer as fluid resuscitation during the emergent phase of burn recovery?

  • A. Colloids
  • B. Crystalloids
  • C. Fresh-frozen plasma
  • D. Packed red blood cells

Correct Answer: B. Crystalloids

Although not universally true, most fluid resuscitation for burn injuries starts with crystalloid solutions, such as normal saline and Ringer’s lactate. Burn patients receive a larger amount of fluids in the first hours than any other trauma patients. Initial resuscitation is based on crystalloids because of the increased capillary permeability occurring during the first 24 h. After that time, some colloids, but not all, are accepted.

  • Option A: Colloids are not generally used during the fluid shift phase because these large particles pass through the leaky capillaries into the interstitial fluid, where they increase the osmotic pressure. Increased osmotic pressure in the interstitial fluid can worsen the capillary leak syndrome and make maintaining the circulating fluid volume even more difficult.
  • Option C: Fresh frozen plasma appears to be a useful and effective immediate burn resuscitation fluid but its benefits must be weighed against its costs, and risks of viral transmission and acute lung injury. 
  • Option D: The burn client rarely requires blood during the emergent phase unless the burn is complicated by another injury that involves hemorrhage. Ongoing blood loss, anemia, hypoxia, and cardiac disease are the most common reasons for blood transfusion in burn patients. Other important causes include age, percentage of burn (TBSA), need for further operation, presence of acute respiratory distress syndrome, sepsis, and evidence of cardiac ischemia.

NURSESLABS-BURNINJURY-04-012

The client with a dressing covering the neck is experiencing some respiratory difficulty. What is the nurse’s best first action?

  • A. Administer oxygen.
  • B. Loosen the dressing.
  • C. Notify the emergency team.
  • D. Document the observation as the only action.

Correct Answer: B. Loosen the dressing.

Respiratory difficulty can arise from external pressure. The first action in this situation would be to loosen the dressing and then reassess the client’s respiratory status. Generally, it is recommended that pressure should be maintained between 20 and 30 mm Hg, which is above capillary pressure but less than what would diminish peripheral blood circulation.

  • Option A: It is unnecessary to administer oxygen. Wearing pressure garments is uncomfortable and challenging; problems with movement, appearance, fit, comfort, swelling of extremities, rashes, and blistering are common; consequently, low compliance with PGT is to be expected.
  • Option C: The nurse may intervene first. However, monitoring of pressure exerted by pressure garments is currently difficult and time-consuming, and not routinely done and currently, the optimal pressure magnitude for PGT remains unsolved.
  • Option D: The nurse may loosen the dressing to help the client breathe. Recent evidence suggests that pressure garment therapy is effective for the prevention and/or treatment of abnormal scarring after burn injury but that the clinical benefit is restricted to those patients with moderate or severe scarring.

NURSESLABS-BURNINJURY-04-013

The client who experienced an inhalation injury 6 hours ago has been wheezing. When the client is assessed, wheezes are no longer heard. What is the nurse’s best action?

  • A. Raise the head of the bed.
  • B. Notify the emergency team.
  • C. Loosen the dressings on the chest.
  • D. Document the findings as the only action.

Correct Answer: B. Notify the emergency team.

Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose the effective movement of air. When this occurs, wheezing is no longer heard and neither are breath sounds. The client requires the establishment of an emergency airway and the swelling usually precludes intubation.

  • Option A: Raising the head of the bed would be not much help because of the obstructed airway. Airway protection should include considering early and preemptive intubation for patients with inhalation injury.
  • Option C: Dressings may be loosened, but emergency intubation would still be needed. Airway edema may occur suddenly as edema worsens, and often, the upper airways develop injury and obstruction earliest, prior to the parenchymal injury.
  • Option D: This is not a normal finding. There may be accessory muscle usage, tachypnea, cyanosis, stridor, and rhonchi/rales/wheezing. Findings of stridor or upper airway turbulence/noise are often a sign of impending airway compromise, and prompt intubation should be strongly considered.

NURSESLABS-BURNINJURY-04-014

Ten hours after the client with 50% burns is admitted, her blood glucose level is 90 mg/dL. What is the nurse’s best action?

  • A. Notify the emergency team.
  • B. Document the finding as the only action.
  • C. Ask the client if anyone in her family has diabetes mellitus.
  • D. Slow the intravenous infusion of dextrose 5% in Ringer’s lactate.

Correct Answer: B. Document the finding as the only action.

Neural and hormonal compensation to the stress of the burn injury in the emergent phase increases liver glucose production and release. An acute rise in the blood glucose level is an expected client response and is helpful in the generation of energy needed for the increased metabolism that accompanies this trauma.

  • Option A: The glucose level is not high enough to alert the emergency team. A variety of laboratory tests will be needed within the first 24 hours of a patient’s admission (some during the initial resuscitative period and others after the patient is stabilized).
  • Option C: A family history of diabetes could make her more of a risk for the disease, but this is not a priority at this time. The secondary assessment shouldn’t begin until the primary assessment is complete; resuscitative efforts are underway; and lines, tubes, and catheters are placed.
  • Option D: Infusion of an IV fluid containing dextrose may further increase the client’s blood glucose. The ideal burn resuscitation is the one that effectively restores plasma volume, with no adverse effects. Isotonic crystalloids, hypertonic solutions, and colloids have been used for this purpose, but every solution has its advantages and disadvantages. None of them is ideal, and none is superior to any of the others.

NURSESLABS-BURNINJURY-04-015

On admission to the emergency department the burned client’s blood pressure is 90/60, with an apical pulse rate of 122. These findings are an expected result of what thermal injury-related response?

  • A. Fluid shift
  • B. Intense pain
  • C. Hemorrhage
  • D. Carbon monoxide poisoning

Correct Answer: A. Fluid shift

The physiologic effect of histamine release in injured tissues is a loss of vascular volume to the interstitial space, with a resulting decrease in blood pressure. After a burn, fluid shifts from vascular to interstitial and intracellular spaces because of increased capillary pressure, increased capillary and venular permeability, decreased interstitial hydrostatic pressure, chemical inflammatory mediators, and increased interstitial protein retention.

  • Option B: Intense pain and carbon monoxide poisoning increase blood pressure. Superficial dermal burns are initially the most painful. Even the slightest change in the air currents moving past the exposed superficial dermis causes a patient to experience excruciating pain. Without the protective covering of the epidermis, nerve endings are sensitized and exposed to stimulation.
  • Option C: Hemorrhage is unusual in a burn injury. The difference with a burn is the heat actually stops the blood from flowing. A small bit of blood may ooze out at first, but it won’t actually bleed much.
  • Option D: Most commonly, patients with carbon monoxide poisoning will present with headache (more than 90%), dizziness, weakness, and nausea. Patients may be tachycardic and tachypneic. They may exhibit hypotension. Mental status changes such as confusion, altered level of consciousness, disorientation, and memory loss may occur.

NURSESLABS-BURNINJURY-04-016

Twelve hours after the client was initially burned, bowel sounds are absent in all four abdominal quadrants. What is the nurse’s best action?

  • A. Reposition the client onto the right side.
  • B. Document the finding as the only action.
  • C. Notify the emergency team.
  • D. Increase the IV flow rate.

Correct Answer: B. Document the finding as the only action.

Decreased or absent peristalsis is an expected response during the emergent phase of burn injury as a result of neural and hormonal compensation to the stress of injury. After the mid and late 1990s, the idea of staged food intake was advanced: a small amount of light fluid is started several hours after burn so as to not only supplement nutrition but stimulate GI peristalsis and improve GI blood supply. Once bowel sound resumes, the amount of food can be increased.

  • Option A: Post-burn GI dysfunction is caused by multiple factors, and therefore maintaining GI function is a systematic engineering project. The therapeutic strategy should not rely on a single treatment or a single drug.
  • Option C: It is suggested that small doses of dopamine should be administered to dilate the renal and GI vessels, and free oxygen radical clearing agents to attenuate ischemia/reperfusion injury in the process of resuscitation. These comprehensive resuscitation measures played an important role in protecting GI function, helping resume bowel sound earlier and digestive function.
  • Option D: In some patients in whom fluid resuscitation was not implemented effectively for various reasons, wound surface infection often caused severe injury to the GI function, or even toxic paralytic ileus palsy, greatly increasing toxin absorption and bacterial superinfection.

NURSESLABS-BURNINJURY-04-017

Which clinical manifestation indicates that the burned client is moving into the fluid remobilization phase of recovery?

  • A. Increased urine output, decreased urine specific gravity
  • B. Increased peripheral edema, decreased blood pressure
  • C. Decreased peripheral pulses, slow capillary refill
  • D. Decreased serum sodium level, increased hematocrit

Correct Answer: A. Increased urine output, decreased urine specific gravity

The “fluid remobilization” phase improves renal blood flow, increasing diuresis and restoring fluid and electrolyte levels. The increased water content of the urine reduces its specific gravity. Injured capillaries heal approximately 24 to 36 hours after a burn, so intravascular fluid loss typically ceases at this time, and fluid begins to shift back into the intravascular compartment. This stage is called the fluid remobilization period.

  • Option B: Edema develops when the rate at which fluid is filtered out of the capillaries exceeds the flow in the lymph vessels. Edema formation often follows a biphasic pattern. An immediate and rapid increase in the water content of burned tissue is seen in the first hour after burn injury.
  • Option C: Inadequate fluid resuscitation is the most common cause of diminished distal pulses in the newly burned patient. Another potential cause of diminished pulses is peripheral edema, which develops in many severe burn patients due to the large fluid volumes needed for resuscitation.
  • Option D: Hyponatraemia is frequent, and the restoration of sodium losses in the burn tissue is, therefore, essential hyperkalemia is also characteristic of this period because of the massive tissue necrosis. Following a severe burn injury, significant hematologic changes occur that are reflected in complete blood count (CBC) measurements. Over the first week after injury, HGB and HCT decreased. This decrease was due to loss of red blood cells. WBC counts were initially elevated but decreased over the first 4 days. PLT also decreased over the first 4 days.

NURSESLABS-BURNINJURY-04-018

What is the priority nursing diagnosis during the first 24 hours for a client with full-thickness chemical burns on the anterior neck, chest, and all surfaces of the left arm?

  • A. Risk for Ineffective Breathing Pattern
  • B. Decreased Tissue Perfusion
  • C. Risk for Disuse Syndrome
  • D. Disturbed Body Image

Correct Answer: C. Risk for Disuse Syndrome

During the emergent phase, fluid shifts into interstitial tissue in burned areas. When the burn is circumferential on an extremity, the swelling can compress blood vessels to such an extent that circulation is impaired distal to the injury, necessitating the intervention of an escharotomy. Chemical burns do not cause inhalation injury.

  • Option A: Chemical burns do not cause inhalation injury and a disrupted breathing pattern. The most common findings represent structural changes to the tissue directly affected, for example, the eye, oral mucosa, skin, esophagus, and lower intestinal system, especially the stomach and pylorus, respiratory system, among others.
  • Option B: During the emergent phase, fluid shifts into interstitial tissue in burned areas. When the burn is circumferential on an extremity, the swelling can compress blood vessels to such an extent that circulation is impaired distal to the injury, causing decreased tissue perfusion and necessitating the intervention of an escharotomy.
  • Option D: Disturbed body image can develop. Assist the patient to identify the extent of actual change in appearance and body function. This helps begin the process of looking to the future and how life will be different.

NURSESLABS-BURNINJURY-04-019

All of the following laboratory test results on a burned client’s blood are present during the emergent phase. Which result should the nurse report to the physician immediately?

  • A. Serum sodium elevated to 131 mmol/L (mEq/L)
  • B. Serum potassium 7.5 mmol/L (mEq/L)
  • C. Arterial pH is 7.32
  • D. Hematocrit is 52%

Correct Answer: B. Serum potassium 7.5 mmol/L (mEq/L)

All these findings are abnormal; however, only the serum potassium level is changed to the degree that serious, life-threatening responses could result. With such a rapid rise in the potassium level, the client is at high risk of experiencing severe cardiac dysrhythmias and death.

  • Option A: Serum sodium is abnormal, but not to the same degree of severity, and would be expected in the emergent phase after a burn injury. Severe cutaneous injuries such as burn injuries and blast injuries result in the loss of both water and sodium. For burn patients, hypernatremia that occurs within a few days of injury may be associated with increased risk of death.
  • Option C: Acid-base studies were carried out on 76 consecutive burn patients admitted within 36 hours of injury. Admission blood pH and base excess (BE) values all decreased in a linear relationship to the extent of the burn. Blood Pco-2 changes were unrelated to the extent of the burn. Significant acidosis developed within 2 hours of burn injury.
  • Option D: The hematocrit (Hct) is the percentage of the volume of the whole blood that is made up of red blood cells. In burns, the patient has lost a lot of fluid from leaky blood vessels. There are more red cells than fluid so the hematocrit is high.

NURSESLABS-BURNINJURY-04-020

The client has experienced an electrical injury, with the entrance site on the left hand and the exit site on the left foot. What is the priority assessment data to obtain from this client on admission?

  • A. Airway patency
  • B. Heart rate and rhythm
  • C. Orientation to time, place, and person
  • D. Current range of motion in all extremities

Correct Answer: B. Heart rate and rhythm

Electric current travels through the body from the entrance site to the exit site and can seriously damage all tissues between the two sites. Early cardiac damage from electrical injury includes irregular heart rate, rhythm, and ECG changes. It is also important to obtain the patient’s cardiac history, including any history of prior arrhythmias.

  • Option A: The airway is not at any particular risk with this injury. Any patient that was in contact with a high voltage source should have continuous cardiac monitoring during evaluation.
  • Option C: These patients are specifically at risk for cardiac damage if the path of the current traversed the heart. One may also consider CT imaging of the head if the patient has altered mental status or associated head trauma from a fall or being thrown in a blast.
  • Option D: Range of motion is also important. However, the priority is to make sure that the heart rate and rhythm are adequate to support perfusion to the brain and other vital organs.
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