ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 62 : Managements of Patients with Burn Injury Questions
Question 1 of 5
A patient has sustained a severe burn injury and is thought to have an impaired intestinal mucosal barrier. Since this patient is considered at an increased risk for infection, what intervention will best assist in avoiding increased intestinal permeability and prevent early endotoxin translocation?
Correct Answer: A
Rationale: Early enteral feeding supports the intestinal mucosal barrier, reducing permeability and preventing endotoxin translocation. Prophylactic antibiotics risk resistant bacteria, and bowel cleansing or stool softeners do not address this issue.
Question 2 of 5
A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurses immediate, priority concern when planning this patients care?
Correct Answer: A
Rationale: Fluid resuscitation is the immediate priority post-cardiopulmonary stabilization to address massive fluid losses through damaged skin, preventing hypovolemic shock. Infection, nutrition, and coping are addressed later.
Question 3 of 5
The nurse is preparing the patient for mechanical debridement and informs the patient that this will involve which of the following procedures?
Correct Answer: B
Rationale: Mechanical debridement involves manually removing eschar with tools like scissors or forceps until pain and bleeding indicate viable tissue. Spontaneous separation is natural debridement, shaving is surgical, and early closure is not debridement.
Question 4 of 5
A patient with a partial-thickness burn injury had Biobrane applied 2 weeks ago. The nurse notices that the Biobrane is separating from the burn wound. What is the nurses most appropriate intervention?
Correct Answer: C
Rationale: As Biobrane separates naturally from a healing wound, trimming the loose edges is appropriate, leaving the adhered portion intact. Reinforcing, replacing, or notifying the physician is unnecessary.
Question 5 of 5
An emergency department nurse learns from the paramedics that they are transporting a patient who has suffered injury from a scald from a hot kettle. What variables will the nurse consider when determining the depth of burn?
Correct Answer: A
Rationale: Burn depth is determined by factors like the causative agent (e.g., scalding liquid), temperature, contact duration, and skin thickness. Preinjury health, prognosis, and accident circumstances are not direct determinants.