NCLEX Burn Injury Nursing Management Practice Exam

NCLEX Burn Injury Nursing Management Practice Exam

 

A patient with severe burns is admitted to the emergency department. What is the priority nursing action?

Administer pain medication
B. Begin fluid resuscitation
C. Apply antibiotic ointment to the burns
D. Cover the burns with sterile dressings

A burn patient’s urine output drops to 20 mL/hr. What should the nurse do first?

Increase fluid infusion rate
B. Check the urinary catheter for patency
C. Notify the healthcare provider
D. Administer a diuretic as prescribed

Which electrolyte imbalance is most common during the emergent phase of a burn injury?

Hypercalcemia
B. Hypokalemia
C. Hyperkalemia
D. Hypomagnesemia

A nurse assesses a patient with electrical burns. Which complication is the patient at greatest risk for?

Infection
B. Cardiac dysrhythmias
C. Renal failure
D. Respiratory distress

When applying silver sulfadiazine to a burn, the nurse knows that:

It is applied directly to the wound bed and covered with a dressing.
B. It is left open to the air for better absorption.
C. It should only be used for full-thickness burns.
D. A thick layer should be applied to promote healing.

Which of the following is a sign of inhalation injury in a burn patient?

Bright red blood in the sputum
B. Hoarseness and stridor
C. Clear breath sounds on auscultation
D. Normal oxygen saturation

A patient with burns develops blisters filled with clear fluid. These burns are classified as:

Superficial burns
B. Superficial partial-thickness burns
C. Deep partial-thickness burns
D. Full-thickness burns

During the acute phase of burn care, the primary focus is:

Pain management
B. Infection prevention
C. Fluid resuscitation
D. Wound closure

Which intervention helps prevent contractures in burn patients?

Applying compression garments
B. Encouraging bedrest
C. Performing active and passive range of motion exercises
D. Avoiding the use of splints

The Parkland formula for fluid resuscitation is calculated based on:

Body weight
B. Percentage of total body surface area burned
C. Age of the patient
D. Duration of the burn exposure

A patient with 40% TBSA burns is in the rehabilitation phase. The nurse should prioritize:

Preventing infection
B. Maintaining fluid balance
C. Promoting mobility and function
D. Managing electrolyte imbalances

A burn patient is at risk for Curling’s ulcer. What medication might be prescribed to prevent it?

Antibiotics
B. Proton pump inhibitors
C. Analgesics
D. Diuretics

In patients with burns, escharotomy is performed to:

Prevent hypertrophic scarring
B. Relieve circulatory compromise
C. Reduce infection risk
D. Promote wound healing

What dietary recommendation is appropriate for a burn patient in the acute phase?

High-protein, high-calorie diet
B. Low-protein, low-sodium diet
C. High-carbohydrate, low-fat diet
D. Low-calorie, low-sodium diet

Which assessment finding suggests that fluid resuscitation is effective?

Heart rate of 120 bpm
B. Central venous pressure (CVP) of 1 mm Hg
C. Urine output of 50 mL/hr
D. Systolic blood pressure of 85 mm Hg

What type of dressing is used for burns that require autografting?

Wet-to-dry dressing
B. Dry sterile gauze
C. Non-adherent dressing
D. Occlusive hydrocolloid dressing

A patient reports pain during wound care. The nurse’s best action is to:

Perform wound care quickly
B. Administer prescribed analgesics before wound care
C. Teach relaxation techniques during the procedure
D. Encourage the patient to tolerate the pain

In the resuscitation phase, a burn patient is most at risk for:

Hypovolemia
B. Hypervolemia
C. Hypocalcemia
D. Hypernatremia

Which diagnostic test is most critical for assessing a burn patient with suspected smoke inhalation?

Serum carboxyhemoglobin levels
B. Complete blood count (CBC)
C. Electrocardiogram (ECG)
D. Blood urea nitrogen (BUN)

The nurse knows a patient with burns needs further teaching when they state:

“I should wear sunscreen when I go outside.”
B. “I’ll use moisturizers to keep my skin soft.”
C. “I should avoid wearing pressure garments to feel more comfortable.”
D. “I’ll eat foods high in protein to help my recovery.”

What is a priority concern for a patient with burns over 50% of the body?

Chronic pain
B. Hypothermia
C. Sepsis
D. Fluid overload

Which sign indicates an adequate airway in a patient with burns?

Pink, moist mucous membranes
B. Hoarse voice
C. Singed nasal hairs
D. Inspiratory stridor

A patient receiving fluid resuscitation for burns complains of abdominal tightness and difficulty breathing. What is the nurse’s priority action?

Reassess fluid rates
B. Notify the healthcare provider immediately
C. Administer pain medication
D. Check the patient’s oxygen saturation

The nurse suspects an infection in a burn wound when:

The wound has a foul odor
B. The wound is dry and healing
C. The patient’s WBC count is within normal limits
D. The wound appears pink and moist

Which intervention minimizes scarring in a burn patient?

Keeping wounds uncovered
B. Applying pressure garments consistently
C. Using cold compresses on the scars
D. Avoiding range-of-motion exercises

 

What is the primary purpose of administering lactated Ringer’s solution in the emergent phase of burn care?

Prevent infection
B. Restore fluid and electrolyte balance
C. Manage pain effectively
D. Promote wound healing

A patient with burns is experiencing confusion and restlessness. The nurse suspects:

Hypovolemia
B. Hyperthermia
C. Hypoxia
D. Electrolyte imbalance

Which statement indicates the patient understands how to care for a burn wound at home?

“I will scrub my wound daily to remove scabs.”
B. “I’ll apply antibiotic ointment and change the dressing daily.”
C. “I should expose my burn to air to help it heal faster.”
D. “I’ll avoid washing the area to prevent infection.”

The nurse identifies which patient as being at the highest risk for burn shock?

A 30-year-old with 10% TBSA burns
B. A 60-year-old with 25% TBSA burns
C. A 45-year-old with 5% TBSA burns
D. A 70-year-old with superficial burns

A patient with facial burns is prescribed a bronchodilator. The nurse understands the purpose is to:

Relieve pain
B. Reduce airway inflammation
C. Improve oxygenation
D. Prevent bronchospasm

What is the first indication of fluid resuscitation adequacy in a burn patient?

Stable blood pressure
B. Urine output >30 mL/hr
C. Decreased heart rate
D. Improved capillary refill

Which intervention is a priority for a burn patient with circumferential burns to the chest?

Wound debridement
B. Escharotomy
C. Fluid resuscitation
D. Intubation

During the rehabilitation phase, the nurse teaches the patient to:

Continue using compression garments
B. Limit physical activity to avoid stress
C. Avoid sun exposure indefinitely
D. Apply heat to the affected area for pain relief

A patient with burns develops a high fever, tachycardia, and hypotension. The nurse suspects:

Fluid overload
B. Sepsis
C. Airway obstruction
D. Electrolyte imbalance

What is a characteristic feature of a full-thickness burn?

Blisters with clear fluid
B. Severe pain
C. Dry, leathery eschar
D. Bright red, moist wound bed

Which nursing diagnosis is a priority in the emergent phase of burn care?

Risk for infection
B. Impaired skin integrity
C. Fluid volume deficit
D. Chronic pain

Which laboratory value is expected in the emergent phase of burn injury?

Hyperkalemia
B. Hypokalemia
C. Hypernatremia
D. Hypoglycemia

A patient asks why their burned hand must remain elevated. The nurse explains:

“It reduces pain.”
B. “It improves circulation.”
C. “It minimizes swelling.”
D. “It accelerates healing.”

What complication is most common in the acute phase of burn care?

Sepsis
B. Dehydration
C. Cardiac arrhythmias
D. Respiratory failure

Which intervention is most effective in preventing infection in burn patients?

Limiting the use of antibiotics
B. Using sterile technique during wound care
C. Keeping wounds open to the air
D. Administering prophylactic antifungal medication

Which medication is commonly used for pain management in burn patients?

Acetaminophen
B. Ibuprofen
C. Morphine sulfate
D. Lidocaine

When caring for a burn patient, the nurse notes a sudden drop in blood pressure and a weak pulse. What is the most likely cause?

Hypervolemia
B. Hypovolemia
C. Septic shock
D. Cardiac arrest

What should the nurse monitor closely during the administration of fluid resuscitation in a burn patient?

Skin turgor
B. Capillary refill
C. Blood pressure
D. Serum potassium levels

Which finding indicates a need for immediate intervention in a burn patient?

Pain level of 7/10
B. Low urine output
C. Clear lung sounds
D. Serum sodium level of 138 mEq/L

The goal of rehabilitation in burn care includes:

Preventing infection
B. Restoring functional ability
C. Managing electrolyte imbalances
D. Providing nutritional support

A burn patient is prescribed a tetanus shot. The nurse explains it is to:

Reduce pain at the burn site
B. Prevent secondary infections
C. Stimulate wound healing
D. Protect against Clostridium tetani infection

Which assessment finding suggests an improvement in a patient with inhalation burns?

Stridor
B. Increased wheezing
C. Clear breath sounds
D. Hoarseness

A burn patient has dark brown urine. The nurse suspects:

Dehydration
B. Rhabdomyolysis
C. Sepsis
D. Electrolyte imbalance

What is the nurse’s priority action when a burn patient develops a temperature of 102°F (38.9°C)?

Notify the healthcare provider
B. Administer prescribed antipyretics
C. Check for signs of infection
D. Increase fluid intake

Which is a priority in the emergent phase of a burn injury?

Preventing hypertrophic scarring
B. Establishing a patent airway
C. Administering enteral nutrition
D. Managing chronic pain

 

The nurse identifies which as a key focus in the rehabilitation phase of burn care?

Pain management
B. Prevention of contractures
C. Fluid resuscitation
D. Treatment of infection

Which clinical sign is most indicative of smoke inhalation injury?

Persistent cough
B. Singed nasal hairs
C. Hoarseness
D. Bright red lips

What is the priority nursing intervention when transferring a burn patient to a higher-level care facility?

Administering antibiotics
B. Applying sterile dressings
C. Maintaining airway and oxygenation
D. Keeping the patient warm

What type of graft is taken from another individual for burn wound coverage?

Autograft
B. Allograft
C. Xenograft
D. Synthetic graft

A patient with extensive burns is experiencing paralytic ileus. The nurse anticipates which intervention?

Initiating oral feedings
B. Inserting a nasogastric tube
C. Administering laxatives
D. Encouraging early ambulation

During the emergent phase of a burn, which electrolyte imbalance is most common?

Hypernatremia
B. Hypokalemia
C. Hyperkalemia
D. Hypocalcemia

Which statement by a patient indicates understanding of compression garments’ purpose?

“They will help prevent infection.”
B. “They are used to reduce scarring.”
C. “They will keep my skin moisturized.”
D. “They will help my wounds close faster.”

What is the nurse’s priority during the acute phase of burn management?

Enhancing mobility
B. Preventing infection
C. Replacing fluid losses
D. Controlling pain

Which of the following is a characteristic of partial-thickness burns?

Painless, leathery appearance
B. Blister formation
C. Exposure of underlying tissues
D. Charred and blackened skin

What should the nurse assess for in a patient with electrical burns?

Fluid imbalance
B. Cardiac dysrhythmias
C. Skin infection
D. Respiratory distress

What is the main goal of nutritional support in burn patients?

Promote weight gain
B. Enhance wound healing
C. Prevent constipation
D. Maintain a low-protein diet

What is the primary risk associated with circumferential burns of the extremities?

Fluid overload
B. Compartment syndrome
C. Severe infection
D. Delayed wound healing

A patient is in the emergent phase of burn care. Which finding requires immediate intervention?

Heart rate of 120 bpm
B. Blood pressure of 90/50 mmHg
C. Urine output of 15 mL/hr
D. Temperature of 100.4°F (38°C)

Which dressing type is most commonly used for burn wounds?

Transparent film
B. Hydrocolloid
C. Silver-impregnated dressings
D. Alginate

Which complication should the nurse monitor for during the rehabilitation phase of a burn injury?

Sepsis
B. Psychological distress
C. Fluid volume overload
D. Hyperkalemia

The nurse is preparing to administer tetanus toxoid to a burn patient. When should this vaccine be administered?

Only if the burn involves muscle tissue
B. If the patient’s vaccination status is unknown
C. Routinely within 48 hours of injury
D. Only in cases of contaminated burns

Which pain management technique is most appropriate for a patient during burn wound debridement?

Oral acetaminophen
B. Distraction techniques only
C. Intravenous opioid analgesics
D. Topical anesthetics

A patient with burn injuries develops curling’s ulcer. The nurse anticipates administering:

Antacids
B. Proton pump inhibitors
C. Antihistamines
D. Antibiotics

What is the primary cause of hypovolemic shock in burn patients?

Blood loss
B. Loss of plasma proteins
C. Excessive evaporation of water
D. Fluid shifts to interstitial spaces

Which action is most important when caring for a patient with burns on the lower extremities?

Keeping the legs elevated
B. Applying heat packs to the wounds
C. Encouraging ambulation early
D. Massaging the affected area regularly

The nurse explains to the family that the eschar on the burn wound:

Protects the wound from infection
B. Indicates deep tissue damage
C. Needs removal to promote healing
D. Will heal on its own over time

A patient has chemical burns. What is the nurse’s first action?

Apply neutralizing agents
B. Rinse the area with copious water
C. Cover the burn with sterile dressing
D. Remove any restrictive clothing

In which scenario should the nurse anticipate an escharotomy?

Superficial partial-thickness burns
B. Circumferential burns with impaired circulation
C. Full-thickness burns on the back
D. Burns covering less than 10% TBSA

A burn patient in the emergent phase exhibits signs of renal failure. The nurse suspects:

Hypovolemia
B. Hemoglobinuria
C. Sepsis
D. Overhydration

Which intervention is most effective for reducing contractures in burn patients?

Range-of-motion exercises
B. Using a heating pad
C. Limiting activity
D. Immobilizing the affected limb

 

What is the first step in managing a thermal burn injury?

Cover the burn with sterile dressings
B. Apply topical antibiotic ointment
C. Remove the source of heat
D. Start intravenous fluids

A patient with facial burns develops wheezing and stridor. What is the priority nursing action?

Administer albuterol
B. Intubate the patient immediately
C. Provide humidified oxygen
D. Assess breath sounds

Which symptom indicates the need for fluid resuscitation in a burn patient?

Clear urine output of 50 mL/hr
B. Serum sodium level of 138 mEq/L
C. Decreased skin turgor and tachycardia
D. Mild peripheral edema

When assessing a patient with an electrical burn, what is the nurse’s priority?

Assessing for fractures
B. Monitoring urine for myoglobin
C. Checking for entry and exit wounds
D. Assessing cardiac rhythm

Which of the following statements is true regarding full-thickness burns?

They are painful due to nerve endings being exposed.
B. They often result in minimal scarring.
C. They require skin grafting for healing.
D. They appear pink and moist.

A patient in the emergent phase of burns exhibits confusion and a fruity breath odor. Which lab value should the nurse prioritize?

Serum potassium
B. Blood glucose
C. Serum sodium
D. Hemoglobin

Why are burn patients at increased risk for hypothermia during the emergent phase?

Decreased oxygen delivery to tissues
B. Heat loss through damaged skin
C. Vasodilation from fluid resuscitation
D. Impaired metabolic function

A patient with burns is receiving total parenteral nutrition (TPN). What is the primary reason for this intervention?

To reduce gastrointestinal distress
B. To prevent hypermetabolic complications
C. To improve protein synthesis for healing
D. To maintain electrolyte balance

What is the priority nursing intervention for a patient with circumferential burns on the chest?

Initiate pain management
B. Monitor oxygen saturation
C. Perform escharotomy
D. Apply a compression dressing

Which finding is most concerning in a burn patient during the acute phase?

Edema at the burn site
B. A heart rate of 90 bpm
C. Greenish drainage from the wound
D. A white blood cell count of 10,000/mm³

The nurse suspects a patient with burns has developed compartment syndrome. What is the priority assessment?

Peripheral pulses
B. Respiratory rate
C. Urine output
D. Skin integrity

What is the most important nursing intervention during the rehabilitation phase of burn care?

Ensuring adequate protein intake
B. Preventing hypertrophic scarring
C. Providing IV fluids
D. Administering antibiotics

Which complication is most likely to occur in the emergent phase of burn care?

Hypervolemia
B. Hypovolemic shock
C. Chronic renal failure
D. Contractures

Why is albumin administered to a burn patient during fluid resuscitation?

To enhance wound healing
B. To reduce the risk of infection
C. To increase intravascular oncotic pressure
D. To prevent electrolyte imbalances

What should the nurse do first when a chemical burn is reported?

Determine the type of chemical involved
B. Flush the affected area with water
C. Remove contaminated clothing
D. Apply neutralizing agents

What lab value is closely monitored in patients with severe burns to detect acute kidney injury?

Hematocrit
B. Serum creatinine
C. Serum calcium
D. Platelet count

A patient with severe burns is receiving IV morphine. What is the primary goal of this intervention?

To decrease inflammation
B. To facilitate mobility exercises
C. To manage acute pain
D. To prevent infection

What is the most common cause of death in burn patients during the acute phase?

Sepsis
B. Hypervolemia
C. Hypothermia
D. Pulmonary embolism

When is surgical debridement typically performed for burn wounds?

During the emergent phase
B. Once granulation tissue is present
C. When the wound shows signs of infection
D. In preparation for grafting

Which patient is at highest risk for complications from burn injuries?

A 12-year-old with partial-thickness burns on the arms
B. A 25-year-old with full-thickness burns on the legs
C. A 45-year-old with circumferential burns on the chest
D. A 60-year-old with burns covering 15% of the body

A burn patient reports tingling and numbness in the hand. What should the nurse suspect?

Local infection
B. Compartment syndrome
C. Nerve regeneration
D. Fluid overload

Which intervention is essential during wound care for a burn patient?

Applying wet-to-dry dressings
B. Maintaining aseptic technique
C. Using occlusive dressings
D. Keeping the wound open to air

A patient with burns is experiencing oliguria. What is the most likely cause during the emergent phase?

Hypernatremia
B. Hypovolemia
C. Hyperkalemia
D. Renal failure

Which medication is most commonly used to reduce scarring in burn patients?

Corticosteroids
B. Vitamin E cream
C. Silvadene (silver sulfadiazine)
D. Compression garments

Which sign indicates a burn wound infection?

Dry wound edges
B. Absence of granulation tissue
C. Purulent drainage
D. Decreased pain at the site

 

A patient with burns is receiving silver sulfadiazine (Silvadene) cream. What is the primary purpose of this medication?

To promote rapid wound healing
B. To provide pain relief
C. To prevent bacterial infection
D. To reduce scar formation

Which of the following is a priority assessment for a patient with burns to the face and neck?

Peripheral pulses
B. Respiratory status
C. Urine output
D. Bowel sounds

A patient with burns develops a temperature of 102°F (38.9°C). What should the nurse suspect?

Normal inflammatory response
B. Onset of infection
C. Hypermetabolic state
D. Dehydration

What is the primary goal during the emergent phase of burn management?

Pain control
B. Infection prevention
C. Fluid resuscitation
D. Nutritional support

Which electrolyte imbalance is commonly seen in the acute phase of burn injury?

Hyperkalemia
B. Hypokalemia
C. Hypernatremia
D. Hyponatremia

A patient with burns is at risk for Curling’s ulcer. What prophylactic treatment is typically initiated?

Proton pump inhibitors
B. Antibiotics
C. Antacids
D. Antiemetics

Which of the following is an early sign of hypovolemic shock in a burn patient?

Bradycardia
B. Hypotension
C. Tachycardia
D. Decreased respiratory rate

What is the purpose of an escharotomy in burn patients?

To remove necrotic tissue
B. To prevent infection
C. To relieve pressure and improve circulation
D. To prepare the wound for grafting

A patient with burns is receiving enteral nutrition. What is the primary reason for this intervention?

To prevent aspiration
B. To maintain bowel function
C. To meet increased metabolic demands
D. To reduce nausea

Which of the following interventions is most appropriate for a burn patient experiencing pruritus during the healing phase?

Administering antihistamines
B. Applying heat packs
C. Encouraging scratching
D. Reducing fluid intake

A patient with burns has a urine output of 20 mL/hr. What should the nurse do first?

Increase the IV fluid rate
B. Assess for signs of renal failure
C. Check the patency of the urinary catheter
D. Notify the healthcare provider

Which of the following is a common complication during the rehabilitation phase of burn recovery?

Fluid overload
B. Contractures
C. Hypothermia
D. Acute respiratory distress syndrome

A patient with burns is prescribed a high-protein diet. What is the rationale for this dietary modification?

To promote wound healing
B. To prevent constipation
C. To reduce the risk of infection
D. To maintain electrolyte balance

What is the primary concern for a patient with electrical burns?

Skin integrity
B. Cardiac arrhythmias
C. Fluid imbalance
D. Pain management

Which of the following is an appropriate intervention for a chemical burn?

Applying ice to the affected area
B. Flushing the area with copious amounts of water
C. Covering the burn with an occlusive dressing
D. Neutralizing the chemical with a specific antidote

A patient with burns is receiving lactated Ringer’s solution. What is the primary purpose of this fluid?

To provide electrolytes
B. To expand blood volume
C. To correct acidosis
D. To supply calories

Which of the following findings indicates effective fluid resuscitation in a burn patient?

Heart rate of 110 bpm
B. Urine output of 0.5 mL/kg/hr
C. Blood pressure of 90/60 mmHg
D. Serum sodium level of 150 mEq/L

A patient with burns is experiencing anxiety. Which intervention is most appropriate?

Administering a benzodiazepine
B. Providing detailed information about procedures
C. Encouraging visitors to stay at the bedside
D. Limiting the use of analgesics

What is the primary purpose of applying compression garments to burn scars?

To reduce pain
B. To prevent infection
C. To minimize hypertrophic scarring
D. To improve circulation

A patient with burns is scheduled for debridement. What is the primary goal of this procedure?

To reduce pain
B. To remove necrotic tissue
C. To apply skin grafts
D. To prevent contractures

Which of the following is a sign of inhalation injury in a burn patient?

Hoarseness
B. Hypotension
C. Bradycardia
D. Hypothermia

A patient with burns is receiving morphine for pain management. What is the most important assessment before administering this medication?

Respiratory rate
B. Blood pressure
C. Heart rate
D. Temperature

Which of the following interventions is most appropriate for preventing contractures in a burn patient?

Immobilizing the affected area
B. Performing passive range-of-motion exercises
C. Applying moist dressings
D. Administering muscle relaxants

A patient with burns has a hematocrit level of 55%. What does this indicate?

Anemia
B. Hemoconcentration
C. Hemodilution
D. Leukocytosis

Which of the following is a priority intervention for a patient with circumferential burns of the extremities?

Elevating the extremities
B. Applying ice packs
C. Performing escharotomy
D. Administering diuretics

 

A patient with burns has an elevated white blood cell count. What is the nurse’s priority action?

Assess for signs of infection
B. Administer an antipyretic
C. Increase fluid intake
D. Obtain a blood culture

During the emergent phase of burn injury, the nurse observes that the patient’s urine output is 30 mL/hour. What does this indicate?

Adequate fluid resuscitation
B. Dehydration
C. Acute renal failure
D. Hyperkalemia

Which of the following is the most appropriate treatment for a minor burn (first-degree burn)?

Applying ice to the burn
B. Covering the burn with a sterile dressing
C. Applying silver sulfadiazine
D. Administering oral morphine for pain

What is the expected fluid replacement volume for a patient with burns, based on the Parkland formula, during the first 24 hours?

2 mL of Ringer’s solution per kg of body weight
B. 4 mL of Ringer’s solution per kg of body weight
C. 5 mL of Ringer’s solution per kg of body weight
D. 3 mL of saline per kg of body weight

Which of the following is the most appropriate nursing intervention for a patient with burns who is in severe pain?

Administering the prescribed opioid analgesic
B. Applying a cold compress to the burn site
C. Encouraging the patient to ambulate
D. Placing the patient in a prone position

A burn patient is receiving intravenous fluids. Which of the following would be an indication of fluid overload?

Increased urine output
B. Decreased blood pressure
C. Edema in extremities
D. Increased respiratory rate

A patient with burns is at risk for developing a hypoglycemic event due to metabolic changes. What is the most appropriate intervention?

Administering insulin as prescribed
B. Providing a carbohydrate-rich snack
C. Monitoring blood glucose levels regularly
D. Limiting fluid intake

What is the main reason for using silver sulfadiazine (Silvadene) on burn wounds?

To promote healing by reducing inflammation
B. To prevent bacterial infection in the burn area
C. To relieve the pain associated with burns
D. To increase circulation in the burn area

Which of the following is an early sign of sepsis in a burn patient?

Increased heart rate
B. Normal blood pressure
C. Decreased white blood cell count
D. Hyperthermia

A patient with burns is being treated with colloid solution. What is the purpose of colloids in burn treatment?

To provide energy
B. To replace lost plasma proteins
C. To correct electrolyte imbalances
D. To treat metabolic acidosis

A burn patient is experiencing increased pain and restlessness. The nurse should first:

Administer pain medication as prescribed
B. Perform a thorough assessment of the wound
C. Notify the healthcare provider
D. Apply a cold compress to the affected area

What is the best indication that a patient is receiving an adequate amount of fluids after a burn injury?

Weight gain of 2 kg
B. Urine output of 0.5 mL/kg/hr
C. Heart rate of 60 bpm
D. Increased blood pressure

What should be the nurse’s first priority when caring for a patient with a chemical burn?

Administer pain medication
B. Remove the chemical from the skin
C. Apply a sterile dressing
D. Apply an antimicrobial ointment

The nurse is caring for a patient who has burns to the chest and neck. The nurse should be most concerned about:

Impaired airway clearance
B. Decreased cardiac output
C. Renal failure
D. Gastrointestinal distress

Which of the following interventions is most appropriate for a patient with burns who is in the rehabilitation phase?

Limiting physical therapy to prevent overstretching of the skin
B. Teaching the patient about proper skin care and protection
C. Decreasing fluid intake to reduce edema
D. Promoting bed rest to prevent fatigue

A patient with burns is receiving morphine for pain. What should the nurse monitor closely?

Blood pressure
B. Respiratory rate
C. Temperature
D. Heart rate

A burn patient is showing signs of hypovolemic shock. What is the priority action by the nurse?

Administer a blood transfusion
B. Increase IV fluids rapidly
C. Administer morphine for pain relief
D. Obtain a chest x-ray

What is the primary goal in the emergent phase of burn injury?

Restoring normal skin integrity
B. Preventing infection
C. Preventing metabolic imbalances
D. Maintaining fluid balance

A patient with burns is at high risk for developing a pulmonary embolism. What is the nurse’s best action to prevent this complication?

Elevate the patient’s legs
B. Monitor oxygen levels regularly
C. Administer prophylactic anticoagulants
D. Encourage deep breathing and coughing exercises

In the rehabilitation phase of burn recovery, the nurse is teaching the patient about the use of pressure garments. The patient asks why these garments are necessary. The nurse’s best response is:

“They help reduce scarring and prevent contractures.”
B. “They will increase circulation to your burn areas.”
C. “They are used to reduce the risk of infection.”
D. “They help in the healing of the burn wounds.”

Which of the following is a common complication in the recovery phase of burn injury?

Hypovolemic shock
B. Infection
C. Cardiac arrhythmias
D. Respiratory distress

The nurse is assessing a patient who was burned with hot oil. Which assessment finding would indicate a deep partial-thickness burn?

Red, dry, and nonblistering skin
B. Blistered skin with significant pain
C. White, waxy skin with no pain
D. Pink skin with intact capillary refill

The nurse is caring for a patient with burns and is providing nutritional support. What is the most important aspect to monitor in these patients?

Protein intake
B. Carbohydrate intake
C. Sodium intake
D. Fat intake

 

A patient with burns has increased serum potassium levels. The nurse understands that this is most likely due to:

Dehydration
B. Cellular breakdown from burn injury
C. Renal failure
D. Excessive fluid resuscitation

A burn patient is experiencing respiratory distress. Which of the following interventions should the nurse prioritize?

Administering oxygen via nasal cannula
B. Increasing the IV fluid rate
C. Assisting the patient into a sitting position
D. Monitoring heart rate and blood pressure

What is the most important nursing assessment for a patient in the emergent phase of burn injury?

Assessment of pain levels
B. Monitoring urine output
C. Assessing for signs of infection
D. Checking for signs of shock

A patient with burns is at risk for compartment syndrome. The nurse should monitor for:

Decreased peripheral pulses
B. Increased body temperature
C. Increased urine output
D. Shallow, rapid respirations

What is the priority goal of care for a patient with a major burn injury in the acute phase of treatment?

Pain management
B. Prevention of infection
C. Fluid resuscitation
D. Early ambulation

A patient with burns is experiencing extreme pain. The nurse administers prescribed morphine. What is the best nursing action following the administration of this medication?

Encourage the patient to eat and drink
B. Reassess the pain level in 30 minutes
C. Restrict fluid intake to prevent swelling
D. Ask the patient to walk around to relieve pain

What is the best nursing intervention for a burn patient who is at risk for impaired skin integrity?

Applying a cool compress to reduce pain
B. Keeping the patient’s skin clean and moist
C. Repositioning the patient every 2 hours
D. Administering antibiotics to prevent infection

A burn patient is receiving enteral nutrition. The nurse should monitor for which of the following potential complications?

Diarrhea
B. Hyperglycemia
C. Weight loss
D. Hypokalemia

A burn patient is experiencing significant edema. What is the best intervention to prevent complications related to edema?

Elevating the affected limbs
B. Administering diuretics
C. Applying pressure stockings
D. Limiting fluid intake

Which of the following is a key consideration when providing wound care for a burn patient?

Applying ice to the burn area
B. Using sterile technique to prevent infection
C. Changing dressings every 8 hours
D. Encouraging the patient to scratch the wound to promote healing

A burn patient who is in the emergent phase has a respiratory rate of 32 breaths per minute and an oxygen saturation of 90%. What is the nurse’s priority action?

Increase the oxygen flow rate
B. Administer bronchodilators
C. Assist with deep breathing exercises
D. Prepare for intubation

The nurse is caring for a burn patient who has a partial-thickness burn. What is the expected healing time for this injury?

3 to 6 weeks
B. 6 to 12 weeks
C. 1 to 2 years
D. 1 to 3 months

A patient is receiving morphine for burn pain. The nurse should be aware that morphine can cause:

Hypotension
B. Diarrhea
C. Urinary retention
D. Tachycardia

A burn patient has a large burn on the left arm and is experiencing hypovolemic shock. What is the primary nursing action in response to this finding?

Increase IV fluids to restore circulating volume
B. Administer pain medications as ordered
C. Elevate the left arm above the level of the heart
D. Apply a cooling compress to the burn site

The nurse is assessing a burn patient’s laboratory values. Which of the following findings would indicate that the patient is at risk for infection?

Decreased white blood cell count
B. Increased hemoglobin levels
C. Low potassium levels
D. Increased glucose levels

A burn patient has been receiving fluid resuscitation for 24 hours. What should the nurse assess to evaluate the patient’s response to therapy?

Urine output and vital signs
B. Pain level and body temperature
C. Oxygen saturation and respiratory rate
D. Blood glucose and renal function

The nurse is planning care for a patient in the rehabilitative phase of burn recovery. What is the most important nursing intervention at this time?

Pain management
B. Emotional support and counseling
C. Promoting independence in activities of daily living
D. Preventing infection and skin care

A burn patient who has been receiving high-flow oxygen therapy is now exhibiting a red, flushed complexion. The nurse should:

Continue oxygen therapy
B. Discontinue oxygen therapy immediately
C. Increase oxygen flow rate
D. Reassess the patient’s oxygen saturation level

Which of the following is an appropriate nursing diagnosis for a burn patient in the emergent phase?

Risk for impaired skin integrity
B. Anxiety related to the burn injury
C. Risk for infection related to burn wounds
D. Knowledge deficit related to burn care

A patient with burns is receiving a blood transfusion. The nurse should closely monitor for:

Hemolytic reaction
B. Electrolyte imbalances
C. Pulmonary edema
D. Renal failure

A burn patient has developed a chemical burn from exposure to a cleaning agent. What is the nurse’s priority action?

Applying cool water to the burn area
B. Removing contaminated clothing and irrigating the burn
C. Applying ointment to the burn site
D. Administering oral analgesics

A burn patient is receiving a large amount of IV fluids. What is the nurse’s priority concern regarding fluid resuscitation?

Electrolyte imbalance
B. Fluid overload
C. Pain management
D. Infection risk

 

A burn patient is receiving a tetanus toxoid vaccine. The nurse understands that this vaccine is given to:

Prevent pain associated with the burn injury
B. Prevent infection from tetanus
C. Promote faster healing of the burn wounds
D. Treat the burn injury

A patient is receiving morphine for pain management following a burn injury. The nurse understands that the primary side effect of morphine to monitor for is:

Hyperthermia
B. Respiratory depression
C. Tachycardia
D. Diarrhea

A burn patient is in the emergent phase and has been intubated. What is the primary goal for the nurse during the intubation process?

Prevent infection
B. Maintain airway patency
C. Promote comfort
D. Ensure adequate fluid resuscitation

A burn patient in the acute phase is being prepared for hydrotherapy. The nurse should:

Ensure the room temperature is comfortable
B. Keep the patient in a sitting position during therapy
C. Avoid giving pain medications before therapy
D. Instruct the patient to remove all jewelry

A burn patient in the emergent phase has developed a decreased level of consciousness. The nurse should:

Reassess the airway and oxygenation
B. Increase the rate of IV fluids
C. Monitor for signs of infection
D. Administer pain medication

A burn patient is receiving fluid resuscitation. Which of the following laboratory values indicates the need to adjust the rate of IV fluid administration?

Increased serum sodium level
B. Decreased blood urea nitrogen (BUN) level
C. Decreased hematocrit level
D. Decreased urine output

The nurse is assessing a burn patient and notes that the patient has a history of cardiac disease. Which of the following interventions should the nurse prioritize?

Administering pain medications
B. Monitoring fluid status carefully
C. Encouraging deep breathing exercises
D. Increasing the frequency of dressing changes

A burn patient is being transferred to the rehabilitation phase. The nurse should focus on which of the following during this phase?

Pain relief
B. Preventing infection
C. Restoring mobility and independence
D. Monitoring for hypovolemia

The nurse is caring for a burn patient who is in the emergent phase. Which of the following assessments should the nurse prioritize?

Pain level
B. Respiratory function
C. Fluid balance
D. Skin graft site

A burn patient is receiving a high-calorie, high-protein diet to promote healing. What should the nurse monitor closely?

Electrolyte imbalance
B. Urinary retention
C. Blood glucose levels
D. Respiratory rate

A patient with a large burn injury is receiving IV fluids for resuscitation. The nurse observes that the patient’s extremities are cool and pale. What is the nurse’s priority action?

Administer additional pain medication
B. Increase the rate of IV fluid administration
C. Notify the healthcare provider immediately
D. Apply a warm compress to the extremities

A burn patient is receiving IV fluids, and the nurse notices that the patient’s urine output has decreased. What is the most appropriate action?

Increase the rate of IV fluids
B. Monitor the urine output every hour
C. Administer diuretics as ordered
D. Assess for signs of renal failure

The nurse is providing education to a burn patient about the importance of preventing infection. Which statement by the patient indicates understanding?

“I should wash my hands frequently and keep the burn clean and dry.”
B. “I will apply lotion to my burn area every 2 hours.”
C. “I should expose my burns to air to speed up healing.”
D. “I will avoid taking pain medications to prevent infection.”

A burn patient is being assessed for signs of compartment syndrome. Which of the following findings would indicate the need for urgent intervention?

Increased pulse rate
B. Cool, pale extremities
C. Increased appetite
D. Decreased respiratory rate

The nurse is assessing a burn patient for signs of infection. Which of the following findings would be most concerning?

Redness around the burn area
B. Clear exudate from the wound
C. Temperature of 100.4°F (38°C)
D. Greenish-yellow exudate from the wound

A burn patient is receiving a dressing change. The nurse should use which of the following techniques?

Apply the dressing tightly to prevent infection
B. Wear sterile gloves and use sterile technique
C. Encourage the patient to apply their own dressing
D. Leave the wound exposed to air to promote faster healing

A burn patient is showing signs of anxiety. The nurse should:

Ignore the patient’s concerns about the injury
B. Provide reassurance and listen to the patient’s concerns
C. Administer sedatives as needed
D. Encourage the patient to exercise to relieve stress

A burn patient is receiving parenteral nutrition. The nurse should monitor for which of the following complications?

Infection at the insertion site
B. Hyperglycemia
C. Hypertension
D. Hypokalemia

A burn patient is receiving pain medication, and the nurse observes that the patient is increasingly drowsy. The nurse should:

Administer a higher dose of pain medication
B. Reassess the patient’s pain level
C. Notify the healthcare provider about the sedation
D. Allow the patient to sleep as much as possible

A burn patient is in the rehabilitation phase and expresses concerns about body image. The nurse should:

Ignore the patient’s concerns
B. Provide support and encourage discussions about body image
C. Reassure the patient that they will look the same after healing
D. Encourage the patient to stay away from mirrors

A burn patient is receiving fluid resuscitation. Which of the following would indicate that the patient is not receiving adequate fluid volume?

Weight gain
B. Increased urine output
C. Warm, pink skin
D. Hypotension

The nurse is caring for a burn patient and notices signs of infection at the burn site. The priority intervention is to:

Administer antibiotics as ordered
B. Clean the burn site with sterile water
C. Notify the healthcare provider
D. Apply a fresh dressing to the wound

 

A burn patient is showing signs of hypovolemic shock. The nurse should prioritize which intervention?

Administering high-dose steroids
B. Maintaining airway patency
C. Administering IV fluids rapidly
D. Giving pain medications

A patient with burns is receiving analgesics. The nurse should be most concerned if the patient shows signs of:

Hypertension
B. Hyperglycemia
C. Respiratory depression
D. Tachycardia

The nurse is caring for a burn patient who has a history of heart disease. The priority nursing intervention is:

Encourage adequate fluid intake
B. Monitor cardiac rhythm and vital signs closely
C. Promote mobility and exercise
D. Assess pain levels regularly

During the emergent phase of burn care, which of the following interventions is most important in the first 24 hours?

Wound debridement
B. Fluid resuscitation
C. Pain management
D. Psychosocial support

A burn patient is undergoing daily wound care. Which of the following interventions should be included in the care plan to prevent infection?

Removing all dressings as quickly as possible
B. Using sterile technique to change the dressings
C. Applying ointments to the burn wounds every 2 hours
D. Exposing the wounds to air for 10 minutes after each dressing change

A burn patient is having trouble breathing and is noted to have soot in the nasal passages. The nurse should:

Administer a nebulized bronchodilator
B. Prepare for intubation and secure the airway
C. Offer the patient oxygen via nasal cannula
D. Encourage coughing to clear the airways

The nurse is educating a burn patient about nutrition. Which statement by the patient indicates a need for further teaching?

“I will eat high-protein foods to help with my healing.”
B. “I should avoid fruits and vegetables to prevent infection.”
C. “I should drink plenty of fluids to stay hydrated.”
D. “I should eat a high-calorie diet to support my healing process.”

A patient with burns is experiencing pain during dressing changes. The nurse should:

Wait until the dressing changes are complete to administer pain medication
B. Administer pain medication 30 minutes before dressing changes
C. Avoid giving pain medication, as it may interfere with healing
D. Use distraction techniques, such as television or music, during the procedure

A burn patient in the emergent phase is receiving a blood transfusion. The nurse should closely monitor for which complication?

Anaphylaxis
B. Hypothermia
C. Hypertension
D. Hypoglycemia

A burn patient has an indwelling catheter inserted for urinary output monitoring. The nurse should prioritize:

Checking the catheter frequently for blockage
B. Removing the catheter every 48 hours
C. Applying a topical antibiotic around the insertion site
D. Keeping the catheter bag above the level of the bladder

A burn patient is at risk for fluid overload due to aggressive fluid resuscitation. The nurse should monitor which of the following signs of fluid overload?

Decreased blood pressure
B. Decreased urine output
C. Weight loss
D. Pulmonary edema

The nurse is caring for a burn patient who is beginning to show signs of infection in the wound. The first priority action is to:

Begin systemic antibiotics
B. Obtain a culture from the wound
C. Apply a fresh dressing to the wound
D. Notify the healthcare provider

A burn patient is showing signs of stress and anxiety. The nurse should:

Encourage the patient to talk about their feelings
B. Offer relaxation techniques such as deep breathing
C. Suggest that the patient focus on the future
D. Discourage the patient from discussing their fears

A burn patient is in the rehabilitation phase and is experiencing pruritus (itching). Which of the following interventions should the nurse suggest?

Apply astringent solutions to the skin
B. Use moisturizing lotions regularly
C. Avoid scratching the affected areas
D. Keep the skin exposed to air as much as possible

The nurse is preparing to administer pain medication to a burn patient. Which of the following is a priority consideration before administering narcotics?

Assessing the patient’s blood pressure
B. Ensuring the patient has an IV line in place
C. Checking the patient’s respiratory rate
D. Confirming the patient’s level of consciousness

A burn patient is admitted with third-degree burns to both hands. Which of the following is a priority for the nurse to assess?

Range of motion and functional ability of the hands
B. Level of pain the patient is experiencing
C. Fluid balance and urine output
D. Degree of wound healing and signs of infection

A patient with burns is receiving parenteral nutrition. The nurse should monitor for signs of:

Hypercalcemia
B. Hyperglycemia
C. Hypokalemia
D. Hypertension

A patient with severe burns is at risk for developing compartment syndrome. Which of the following findings would indicate this complication?

Increased blood pressure
B. Severe pain with passive range of motion
C. Decreased capillary refill in the extremities
D. Decreased urine output

The nurse is providing discharge teaching to a burn patient. Which of the following instructions should be emphasized?

“You can return to work when your wounds are completely healed.”
B. “You should avoid wearing sunscreen for the first few weeks.”
C. “You need to keep your burned skin moisturized to prevent scarring.”
D. “It is important to avoid any type of physical therapy for at least 3 months.”

A burn patient is experiencing fluid shift during the acute phase. The nurse should monitor the patient closely for:

Increased urine output
B. Decreased blood pressure
C. Weight loss
D. Elevated heart rate

A burn patient who sustained a burn to the face is at high risk for:

Respiratory distress
B. Fluid overload
C. Renal failure
D. Cardiovascular collapse

The nurse is assessing a burn patient with a history of asthma. What is the most important intervention for this patient?

Administer a bronchodilator as needed
B. Keep the patient in a prone position to improve oxygenation
C. Monitor the burn wound closely for signs of infection
D. Provide humidified air via a face mask

A burn patient is at risk for nutritional deficiencies. Which of the following would the nurse prioritize in the care plan?

High-protein, high-calorie diet
B. Low-sodium, low-calorie diet
C. High-fat, low-carbohydrate diet
D. Clear liquids until healing is complete

Questions and Answers for Study Guide

 

Discuss the pathophysiological changes that occur during the emergent phase of burn injury and how these changes influence nursing care.

Answer:

The emergent phase of burn injury, which typically lasts for the first 24-48 hours, is marked by significant physiological changes that require immediate and comprehensive nursing care. The pathophysiology of this phase is largely influenced by the extent of the burn injury, the loss of skin integrity, and the resulting fluid shifts.

One of the most notable changes during this phase is fluid shift, where plasma and interstitial fluid move from the intravascular space to the interstitial spaces due to increased vascular permeability. This results in hypovolemia and can lead to shock if not managed adequately. The nurse’s primary role during this phase is to initiate fluid resuscitation based on established guidelines (e.g., the Parkland formula), ensuring the patient receives the necessary intravenous fluids to restore circulating volume and prevent shock.

Another major change is the release of inflammatory mediators like histamine and cytokines, which contribute to edema and systemic inflammation. The nurse should assess for signs of complications such as respiratory distress, especially in cases of burns involving the face and airway. Oxygen therapy and maintaining the patient’s airway are essential nursing interventions.

The temperature regulation of the body is also impaired due to the loss of skin, making the patient at risk for hypothermia. Nurses should maintain warmth by using warming devices, blankets, and ensuring the room temperature is appropriately adjusted.

Finally, pain management is critical during this phase. The nurse must assess the level of pain regularly and administer analgesics, especially prior to wound care or any painful procedures.

In summary, the emergent phase involves fluid resuscitation, airway management, pain control, and monitoring for complications. Nurses must closely observe the patient for signs of shock, respiratory distress, or fluid overload while providing comfort measures and supporting physiological stability.

 

Explain the role of the nurse in the management of burn wound care, including the importance of infection control, wound cleaning, and dressing techniques.

Answer:

Burn wound care is a crucial component in the management of burn patients, and the nurse plays a vital role in ensuring proper treatment to prevent infection, promote healing, and manage pain. Infection control, wound cleaning, and dressing techniques are the cornerstones of burn wound management.

Infection Control
The risk of infection in burn wounds is significant due to the loss of the skin barrier, which serves as the body’s primary defense against pathogens. Infection can lead to sepsis, prolonged hospital stays, and complications that can worsen the patient’s prognosis. Nurses must use aseptic techniques during dressing changes, ensuring that the wound is kept as sterile as possible. Antibiotic therapy, both topical and systemic, may be prescribed depending on the extent and severity of the burn and any signs of infection, such as increased redness, warmth, or purulent drainage.

Wound Cleaning
Proper wound cleaning is essential to remove debris, necrotic tissue, and bacteria, which can delay healing and increase the risk of infection. Gentle cleansing with a mild, non-perfumed soap or saline solution is typically used to cleanse the wound. The nurse should assess the wound for signs of infection, including redness, swelling, and increased drainage, and report any concerns to the healthcare provider promptly.

Dressing Techniques
Dressing the burn wound is critical to protecting the area from external contamination, minimizing pain, and promoting healing. The choice of dressing will depend on the severity and location of the burn. Hydrocolloid dressings, silver sulfadiazine, or biological dressings may be used to protect the wound and provide a moist healing environment. The nurse should also monitor for signs of poor circulation (such as blanching of the skin or cool extremities) if tight dressings are used.

Frequent dressing changes are needed, and the nurse should administer pain medication before performing these changes, as burn wounds are often painful. Additionally, wound assessments should include evaluating the depth and extent of the burn, the presence of eschar or slough, and the progression of healing. Nurses should be diligent in monitoring for complications such as infection or fluid shifts, which can delay recovery.

In summary, effective burn wound care requires a multidisciplinary approach to infection prevention, thorough and gentle wound cleaning, and careful dressing application. Nurses play a pivotal role in ensuring these processes are carried out efficiently and with sensitivity to the patient’s pain and comfort levels.

 

Describe the nursing interventions necessary for managing fluid and electrolyte imbalances in burn patients during the acute phase.

Answer:

The acute phase of burn injury begins when the patient’s condition stabilizes and continues until the patient is fully hemodynamically stable. Fluid and electrolyte imbalances are common during this phase, primarily due to ongoing fluid losses, changes in vascular permeability, and the effects of burn injury on various body systems. Nurses must implement various interventions to manage these imbalances effectively.

Fluid Resuscitation

Initially, the priority is fluid resuscitation during the emergent phase, but it is crucial to continue monitoring and adjusting fluids during the acute phase. After the first 24-48 hours, the nurse must adjust fluid therapy according to the patient’s fluid status, urine output, and laboratory values. The goal is to restore circulating volume, maintain adequate organ perfusion, and prevent renal failure. The nurse should carefully monitor the patient’s urine output, which should ideally be between 30-50 mL/hour in an adult burn patient. If urine output is inadequate, it may indicate inadequate fluid resuscitation or the development of renal compromise, requiring immediate intervention.

Electrolyte Imbalances

Burn injuries can cause significant electrolyte imbalances, such as hyponatremia or hyperkalemia, due to fluid shifts and tissue injury. The nurse should regularly monitor serum sodium and potassium levels, as well as other electrolytes such as chloride, calcium, and magnesium. If hyperkalemia occurs, which is common in the first 24-48 hours due to cell destruction, the nurse must closely observe for signs of cardiac arrhythmias and intervene as needed, potentially administering IV calcium or sodium bicarbonate as prescribed.

Acid-Base Imbalances

The nurse should also be vigilant for acidosis or alkalosis, conditions that can arise from fluid shifts, burns, and the body’s response to stress. For example, metabolic acidosis may occur due to tissue hypoxia or lactic acid buildup. The nurse should monitor arterial blood gases (ABGs) to assess for any abnormalities and work with the healthcare team to correct the imbalances, often through fluid management, medications, and adjustments in nutrition.

Nutritional Support

As burn patients are often in a hypermetabolic state, adequate nutritional support is necessary to promote healing and restore fluid and electrolyte balance. A high-calorie, high-protein diet, sometimes supplemented by parenteral nutrition, is often indicated. The nurse should collaborate with the nutritionist to ensure the patient receives the required nutrients for recovery.

In conclusion, managing fluid and electrolyte imbalances in burn patients requires careful monitoring, prompt interventions, and continuous assessment of the patient’s clinical status. Nurses play a vital role in maintaining fluid balance, correcting electrolytes, and providing essential support to optimize the recovery process.

 

Explain the psychological considerations for burn patients during their recovery and how nurses can provide emotional support.

Answer:

Burn injuries, particularly those that involve significant body surface area and visible scarring, can have profound psychological effects on patients. Nurses must address these emotional and psychological aspects to promote the patient’s overall well-being and recovery. Understanding the psychological stages of burn recovery and providing appropriate emotional support are crucial aspects of nursing care.

Psychological Impact of Burn Injury

Burn patients may experience a range of emotional responses, including shock, denial, anger, depression, and anxiety. The severity of the injury, the level of pain, and the changes in appearance can cause significant body image disturbances and self-esteem issues. Patients may feel ashamed or embarrassed about their appearance, leading to social isolation and difficulties in coping with the reality of their injuries.

Stages of Psychological Recovery

Burn recovery is not just physical—it also involves psychological stages. Initially, patients may experience acute stress reactions such as anxiety, confusion, or irritability. Over time, as patients adjust to their injuries, they may experience feelings of loss and grief due to the changes in their physical appearance and abilities. This can evolve into a sense of disempowerment or helplessness, especially when long-term rehabilitation or reconstructive surgery is required.

Nursing Interventions

Nurses should provide a supportive environment that encourages open communication and expression of feelings. A key nursing intervention is active listening; nurses should provide a safe space for patients to talk about their fears, concerns, and frustrations without judgment. Psychological support can also involve group therapy, one-on-one counseling, or referring the patient to a clinical psychologist specializing in burn recovery.

Additionally, nurses should educate patients about the healing process and realistic outcomes, emphasizing the importance of psychological resilience. Encouraging the patient to engage in self-care activities, such as participating in physical therapy or using compression garments, can improve body image and enhance the patient’s sense of control over their recovery.

Family involvement is another essential aspect of emotional support. Nurses should educate the patient’s family about the emotional challenges the patient may face and encourage family counseling to improve communication and provide collective support.

In conclusion, burn injury recovery involves both physical and psychological healing. Nurses play a crucial role in providing emotional support, promoting psychological resilience, and facilitating coping strategies that help the patient adjust to the challenges of recovery.

 

Describe the nursing interventions involved in managing airway and respiratory complications in burn patients with inhalation injuries.

Answer:

Burn patients, especially those with facial, neck, or upper airway burns, are at significant risk for inhalation injuries, which can cause serious respiratory complications. Prompt recognition and management of airway and respiratory issues are crucial to prevent further deterioration and ensure optimal recovery.

Inhalation Injury and Respiratory Complications

Inhalation injuries are typically caused by the inhalation of hot gases, smoke, or toxic chemicals, and they can result in upper and lower airway obstruction, pulmonary edema, and acute respiratory distress syndrome (ARDS). These injuries may cause laryngeal edema, bronchospasm, carbon monoxide poisoning, or chemical pneumonitis, all of which compromise the patient’s ability to breathe adequately.

Nursing Interventions

1. Airway Assessment and Monitoring
   The nurse should assess the patient for signs of respiratory distress, including stridor, hoarseness, labored breathing, and cyanosis. Immediate attention to airway patency is essential, especially in cases of suspected airway burns. Continuous monitoring of oxygen saturation levels using pulse oximetry and assessing arterial blood gases (ABGs) are important for detecting hypoxia and acidosis.
2. Oxygen Therapy
   High-flow oxygen should be administered as soon as inhalation injury is suspected, particularly to treat carbon monoxide poisoning. 100% oxygen is often used to displace carbon monoxide from hemoglobin. The nurse should ensure that oxygen therapy is titrated to maintain an oxygen saturation of at least 90% and monitor for any signs of carbon dioxide retention or respiratory alkalosis.
3. Intubation and Mechanical Ventilation
   In severe cases of airway compromise, the nurse must be prepared for endotracheal intubation and may need to assist the healthcare provider in securing the airway. Mechanical ventilation may be required if the patient develops respiratory failure or ARDS. Nurses should monitor the ventilator settings and assess for complications such as ventilator-associated pneumonia.
4. Bronchodilators and Inhaled Medications
   If bronchospasm is present, the nurse may administer bronchodilators or steroids as ordered to reduce inflammation and improve airflow. The nurse should monitor the patient for side effects and assess the effectiveness of medications by observing improvement in respiratory parameters.
5. Positioning and Elevation
   To aid in breathing, the nurse should position the patient in a semi-Fowler’s or high-Fowler’s position, which helps optimize lung expansion. For patients with facial or neck burns, elevating the head can also reduce swelling and facilitate easier breathing.
6. Suctioning and Airway Clearance
   In cases where the patient has an impaired ability to clear secretions, the nurse should assist with suctioning to remove secretions from the upper airway and help improve ventilation. Care should be taken not to traumatize the airway during suctioning.

In conclusion, the nurse’s role in managing respiratory complications due to inhalation injuries involves constant monitoring, early intervention to ensure airway patency, administering oxygen and medications, and being prepared for more invasive procedures if necessary. The priority is to prevent airway obstruction and optimize oxygenation and ventilation.

 

Explain the nursing care required for the patient during the rehabilitation phase of burn recovery, with a focus on physical and psychological aspects.

Answer:

The rehabilitation phase of burn recovery focuses on restoring the patient’s functional capacity, both physically and psychologically, as well as preparing them for life after the burn injury. This phase can last from weeks to years and requires continuous nursing care to support the patient’s physical healing, psychological well-being, and overall adjustment to changes in appearance and function.

Physical Rehabilitation

1. Physical Therapy
   During the rehabilitation phase, patients often experience muscle contractures, scarring, and limited mobility due to the formation of hypertrophic scars. Nurses play a key role in ensuring the patient receives adequate physical therapy to maintain joint mobility and prevent contractures. Nurses should assist with active and passive range-of-motion exercises, encourage the use of splints or pressure garments, and promote early mobilization to prevent complications associated with immobility.
2. Wound Care and Scar Management
   Although the burn wound may be healing, ongoing care is required for the treatment of scarring. The nurse should ensure the patient receives appropriate scar management strategies, including the use of silicone gel sheets, pressure garments, and massage therapy. Compression therapy is essential for reducing hypertrophic scarring and improving the cosmetic appearance of the skin.
3. Nutritional Support
   In the rehabilitation phase, the patient’s nutritional needs remain high to support wound healing and muscle regeneration. The nurse should monitor the patient’s caloric intake and collaborate with the dietitian to ensure the patient receives adequate protein, vitamins, and minerals. Enteral nutrition or parenteral nutrition may be required if the patient is unable to maintain an adequate diet orally.

Psychological Rehabilitation

1. Body Image and Self-Esteem
   One of the most significant psychological impacts of burn injuries is the alteration in body image. Burn patients may struggle with feelings of shame, embarrassment, or loss of self-esteem due to visible scarring. Nurses should provide emotional support, encourage positive body image, and offer resources for psychosocial counseling or support groups.
2. Anxiety and Depression
   The psychological stress of dealing with the trauma of a burn injury, coupled with prolonged rehabilitation and potential social stigma, can lead to anxiety and depression. The nurse should routinely assess the patient for signs of mental health distress and provide referrals to a clinical psychologist or psychiatrist for counseling. Nurses can also help by fostering an environment that encourages open expression of feelings and providing coping strategies.
3. Social Reintegration
   As the patient progresses through rehabilitation, they may face challenges in returning to daily activities, including work, school, and social functions. The nurse should assess the patient’s readiness for social reintegration and support their efforts to re-enter society by collaborating with occupational therapists, social workers, and community resources. Rebuilding a support network, improving self-care, and enhancing social participation are essential components of the rehabilitation phase.

In conclusion, the rehabilitation phase is a critical time for burn patients, requiring comprehensive care that addresses both the physical and psychological aspects of recovery. Nurses provide vital support through physical rehabilitation, scar management, and psychosocial interventions to help the patient achieve the best possible outcomes.

 

Discuss the nursing interventions to manage fluid and electrolyte imbalances in burn patients during the resuscitation phase.

Answer:

The resuscitation phase begins immediately after the burn injury and lasts for approximately the first 24-48 hours. During this phase, the body undergoes significant fluid and electrolyte shifts, which can lead to hypovolemic shock, electrolyte imbalances, and renal compromise if not managed appropriately. The nurse plays a crucial role in monitoring fluid status, administering fluid resuscitation, and managing electrolyte imbalances to optimize the patient’s recovery.

Fluid Resuscitation

The primary goal of the resuscitation phase is to restore circulatory volume and prevent hypovolemic shock. Burn injuries lead to a massive shift of fluids from the intravascular space to the interstitial and intracellular spaces due to increased capillary permeability. This can result in severe dehydration and hypotension.

The nurse is responsible for initiating and monitoring fluid resuscitation using isotonic solutions, such as Lactated Ringer’s or normal saline. The Parkland formula (4 mL of fluid per kilogram of body weight per percentage of burn surface area) is often used to guide the amount of fluid needed during the first 24 hours. The nurse should assess for signs of fluid overload (e.g., edema, dyspnea, crackles) and adjust fluid administration accordingly.

Electrolyte Imbalances

Burn patients often experience electrolyte imbalances, particularly hyperkalemia and hyponatremia, due to fluid shifts and cellular damage. The nurse should closely monitor serum potassium and sodium levels, as well as other electrolytes such as calcium and chloride.

1. Hyperkalemia: During the first 24 hours after a burn injury, hyperkalemia can occur due to cellular destruction and release of potassium into the bloodstream. Nurses should monitor for cardiac arrhythmias associated with elevated potassium levels and intervene as needed, often with the administration of IV sodium bicarbonate, calcium gluconate, or insulin and glucose to lower potassium.
2. Hyponatremia: Fluid shifts and dilutional hyponatremia can occur as a result of excessive administration of fluid resuscitation. Nurses should monitor serum sodium levels closely and report any abnormal findings to the healthcare provider. If necessary, hypertonic saline may be administered to correct sodium imbalances.

 

Renal Function and Urine Output

The nurse should also monitor the patient’s renal function, particularly urine output, as kidney function is often compromised during the resuscitation phase due to decreased perfusion and fluid shifts. The nurse should aim for a urine output of 30-50 mL/hour and closely monitor for signs of renal failure, including decreased urine output, dark or concentrated urine, and elevated serum creatinine.

In conclusion, the resuscitation phase is critical for preventing complications from fluid and electrolyte imbalances. Nurses play a central role in fluid resuscitation, electrolyte monitoring, and renal assessment, which are essential for the stabilization of burn patients during the early stages of recovery.

 

Discuss the assessment and nursing interventions for managing pain in burn patients.

Answer:

Burn patients often experience intense pain due to the nature of the injury, which can lead to significant discomfort and suffering. Effective pain management is crucial to improve patient outcomes and enhance the healing process. The nurse must conduct a comprehensive assessment of the patient’s pain and implement appropriate interventions to provide relief.

Assessment of Pain

1. Pain Assessment Tools: The nurse should use standardized pain assessment tools, such as the Numeric Rating Scale (NRS) or the Visual Analog Scale (VAS), to assess pain intensity and determine the need for interventions. For pediatric patients or those unable to communicate effectively, tools like the FLACC scale (Face, Legs, Activity, Cry, Consolability) can be used.
2. Pain Characteristics: It is essential to assess the quality, duration, and location of the pain. Pain in burn patients can be nociceptive, neuropathic, or a combination of both. Nociceptive pain typically results from tissue damage, while neuropathic pain may result from nerve injury or hyperalgesia caused by the burn trauma.
3. Psychosocial Factors: The nurse should also assess for psychosocial factors such as anxiety, depression, or fear, as these can exacerbate pain. Psychological distress can contribute to the perception of pain and may require targeted interventions.

Nursing Interventions for Pain Management

1. Pharmacological Interventions:
   • Opioids: Opioids are often the first-line pharmacological intervention for moderate to severe pain. Drugs such as morphine and fentanyl may be administered intravenously (IV) for rapid onset of pain relief, particularly during the early stages of treatment.
   • Non-Opioid Analgesics: For mild to moderate pain, NSAIDs (e.g., ibuprofen, acetaminophen) can be used in conjunction with opioids to provide adequate pain relief and reduce inflammation.
   • Adjuvant Medications: For neuropathic pain, gabapentin or pregabalin may be used to manage nerve-related discomfort. Local anesthetics (e.g., lidocaine) can also be applied topically to reduce pain during dressing changes.
2. Non-Pharmacological Interventions:
   • Positioning: Positioning the patient in a way that minimizes pressure on burn areas can help alleviate pain. The nurse should provide a comfortable environment with adequate supportive pillows to reduce discomfort.
   • Distraction and Relaxation Techniques: Techniques such as guided imagery, deep breathing exercises, and music therapy can help reduce anxiety and pain perception. Distraction techniques, such as engaging the patient in conversation or watching television, can help take their focus off the pain.
   • Temperature Control: Applying cool compresses to areas of pain can help reduce discomfort, but the nurse must ensure that the compress is not too cold to avoid further skin damage.
3. Psychosocial Support:
   • Patient Education: It is essential to provide the patient and family with education about pain management strategies, the rationale for medication use, and the importance of reporting pain levels regularly.
   • Emotional Support: The nurse should offer emotional support to help the patient cope with pain and the psychological effects of burns. This includes providing reassurance and actively listening to the patient’s concerns.

In conclusion, managing pain in burn patients requires a holistic approach, combining pharmacological and non-pharmacological interventions. Nurses must conduct a thorough pain assessment and use individualized pain management strategies to provide optimal care and improve the patient’s quality of life.

 

Explain the role of the nurse in managing infection control during the burn injury care process.

Answer:

Infection control is a critical component of burn injury care, as patients with burns are at high risk for infections due to the loss of the skin’s protective barrier, which serves as the first line of defense against pathogens. Nurses play an essential role in preventing and managing infections in burn patients to ensure optimal healing and reduce the risk of complications.

Risk Factors for Infection

1. Impaired Skin Integrity: The loss of skin integrity in burn patients makes them highly susceptible to infections caused by bacteria, fungi, or viruses. The depth and extent of the burn wound determine the degree of infection risk.
2. Immune System Dysfunction: Burn injuries lead to significant physiological changes, including immune system suppression, which increases the patient’s susceptibility to infections. This is particularly concerning in patients with large burns or those requiring extensive treatments.
3. Prolonged Hospitalization and Invasive Devices: Burn patients often require long-term hospitalization and the use of invasive devices such as central lines or catheters, which increase the risk of hospital-acquired infections.

Nursing Interventions for Infection Control

1. Wound Care and Dressing Changes:
   • Sterile Technique: The nurse should ensure that all dressing changes are performed using strict aseptic technique to prevent contamination. Using sterile gloves, clean instruments, and sterile dressings is critical to maintaining a clean wound environment.
   • Topical Antimicrobials: Nurses should apply topical antimicrobial agents such as silver sulfadiazine or mupirocin to burn wounds, as these agents help prevent infection by reducing bacterial growth at the wound site.
   • Wound Debridement: In some cases, debridement of necrotic tissue is necessary to prevent bacterial colonization and promote healing. Nurses should ensure that debridement is done carefully to minimize trauma to healthy tissue.
2. Monitoring for Infection:
   • Early Detection: The nurse must monitor the patient for signs of infection, including fever, increased heart rate, elevated white blood cell count, or the presence of purulent discharge from the wound. Blood cultures and wound cultures should be obtained to identify the causative pathogen and guide treatment.
   • Vital Signs Monitoring: Routine assessment of vital signs is essential to detect signs of systemic infection, such as sepsis. The nurse should look for early indications of septic shock or systemic inflammatory response syndrome (SIRS), which require immediate intervention.
3. Antibiotic Therapy:
   • Administration of Antibiotics: If infection is suspected or confirmed, the nurse should assist in the administration of IV antibiotics as prescribed. Broad-spectrum antibiotics may be given initially until culture results are available, at which point targeted therapy can be implemented.
   • Monitoring for Side Effects: The nurse should closely monitor for any adverse reactions to antibiotics, such as allergic reactions or gastrointestinal disturbances, and report these to the healthcare provider.
4. Infection Prevention:
   • Hand Hygiene: The nurse should practice strict hand hygiene before and after patient contact, as this is one of the most effective methods for preventing infection transmission.
   • Environmental Controls: Nurses should ensure that the burn unit environment is kept clean and sterile, especially in areas where burns are treated. This includes cleaning and disinfecting surfaces and ensuring proper waste disposal.
   • Isolation Precautions: If the patient is found to have an infectious organism, appropriate isolation precautions (e.g., contact precautions, airborne precautions) should be implemented to prevent the spread of infection to other patients.

Psychosocial Support and Education
The nurse should educate the patient and family about the importance of infection prevention, including the role of proper wound care, hand hygiene, and recognizing signs of infection. Providing psychological support is also vital, as the stress of dealing with a burn injury can affect the patient’s ability to follow infection control measures.

In conclusion, the nurse plays a key role in preventing and managing infections in burn patients. By implementing strict infection control measures, closely monitoring for signs of infection, and providing ongoing education, nurses can help ensure the best possible outcomes for burn patients.

 

Discuss the principles and techniques involved in fluid resuscitation for burn patients.

Answer:

Fluid resuscitation is a critical component of burn injury management, particularly in the acute phase, where significant fluid loss occurs due to increased capillary permeability, resulting in hypovolemic shock and dehydration. The primary goal of fluid resuscitation is to restore and maintain adequate circulatory volume, support renal function, and prevent shock.

Fluid Resuscitation Principles

1. Parkland Formula: The most widely used formula for calculating the amount of fluid required for the first 24 hours is the Parkland formula, which recommends administering 4 mL of isotonic crystalloid (Lactated Ringer’s or normal saline) per kilogram of body weight per percentage of total body surface area (%TBSA) burned. Half of this total amount should be given during the first 8 hours, and the remaining half during the next 16 hours.
2. Titration Based on Clinical Response: Fluid administration should be titrated based on the patient’s clinical response, such as urine output and vital signs. The goal is to maintain a urine output of 30-50 mL/hour in adults or 1-2 mL/kg/hour in children. Adequate urine output is the best indicator of renal perfusion and reflects proper fluid balance.
3. Isotonic Fluids: During the initial resuscitation phase, isotonic fluids such as Lactated Ringer’s solution or normal saline are used to replace lost intravascular volume and restore electrolyte balance. These fluids help replenish extracellular fluid deficits that occur due to the burn injury.

Techniques of Fluid Resuscitation

1. Invasive Monitoring: In severe cases, the nurse may need to assist in invasive monitoring of the patient’s central venous pressure (CVP) or pulmonary artery pressures (PA pressures) to guide fluid resuscitation, particularly in patients with large burn areas or comorbidities such as cardiac disease.
2. Electrolyte Monitoring: Nurses should monitor serum electrolyte levels throughout fluid resuscitation, especially sodium and potassium, as these can fluctuate significantly during the acute phase. Adjustments in fluid therapy may be necessary to correct hyponatremia or hyperkalemia.
3. Careful Fluid Administration: Care must be taken to avoid fluid overload, which can lead to pulmonary edema, compartment syndrome, and cardiac strain. Monitoring the patient’s vital signs (blood pressure, heart rate), respiratory status, and edema is essential for preventing complications related to fluid resuscitation.

In conclusion, fluid resuscitation is a vital aspect of managing burn patients, and careful attention must be paid to fluid selection, monitoring, and titration. By following established principles and adjusting fluid therapy based on clinical responses, nurses can support the patient’s recovery and minimize the risks associated with fluid imbalances.

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