MSN Exam for Burn Management and Care 2

EXPLANATION

✔Correct answer:

“Can you describe the specific location or environment where the burn injury occurred?” The most crucial question to assess the patient's risk for inhalation injury is asking about the specific location or environment where the burn injury occurred. This information is essential because inhalation injuries are commonly associated with burns sustained in enclosed spaces, such as houses, cars, or industrial buildings, where smoke, heat, and toxic gases are more concentrated. Knowing the environment helps identify whether the patient was exposed to superheated air, smoke, or toxic chemicals (e.g., carbon monoxide or cyanide) that could have damaged their airway or lungs. Patients with inhalation injury may present with symptoms such as hoarseness, singed nasal hairs, soot in the mouth or nose, or respiratory distress, which require immediate intervention to prevent airway compromise.

Think of assessing the environment like tracing the source of a fire alarm. Knowing where the alarm went off (the environment of the burn) helps determine if there was smoke or heat exposure that could have affected the patient's airway.

When assessing for inhalation injury, Nurse Rodriguez should:

• Ask about the burn environment: Clarify whether the patient was in an enclosed space or exposed to prolonged smoke or flame. Inhalation injury is more likely in confined areas.
• Look for physical signs of inhalation injury: Assess for singed nasal hairs, soot around the nose or mouth, carbonaceous sputum, hoarseness, or stridor, which may indicate airway involvement.
• Monitor respiratory status: Check for tachypnea, dyspnea, wheezing, or decreased oxygen saturation. Initiate continuous pulse oximetry monitoring.
• Prepare for advanced airway management: Be ready to assist with intubation if airway swelling or obstruction is suspected, as airway edema can progress rapidly.
• Perform diagnostic testing: Advocate for diagnostic procedures such as bronchoscopy, carboxyhemoglobin levels (to assess carbon monoxide poisoning), or chest X-rays to evaluate the extent of inhalation injury.

✘Incorrect answer options:

“Do you currently smoke cigarettes?” While smoking history is relevant to overall respiratory health, it does not provide specific information about the circumstances of the burn or potential inhalation injury. Smoking status alone is not predictive of whether the patient sustained an inhalation injury.

“When did you last have a chest X-ray performed?” This question is not immediately relevant for determining inhalation injury. A chest X-ray may be ordered to assess lung damage or other complications after inhalation injury is suspected, but the patient’s history of prior imaging is not a priority.

“Have you ever been diagnosed with asthma or any other respiratory conditions?” While a history of asthma or other respiratory conditions may affect the patient’s baseline respiratory function, it does not specifically indicate risk for inhalation injury related to the burn event. The focus should be on the environment of the burn and immediate symptoms.

EXPLANATION

✔Correct answer:

Fluid shift from the intravascular space into the interstitial space. The first 24-48 hours following a significant burn injury are characterized by the "fluid shift phase" or "burn shock phase." During this phase, capillary permeability increases due to the inflammatory response, leading to leakage of plasma and proteins from the intravascular space (blood vessels) into the interstitial space (tissues). This process results in significant edema, hypovolemia, and decreased perfusion to vital organs.

The burn injury causes damage to the capillary walls, leading to increased permeability. This allows plasma proteins, fluid, and electrolytes to escape into the surrounding tissues, causing edema and fluid loss in the vascular compartment. Hypovolemia can lead to shock if not managed promptly with fluid resuscitation. The intravascular volume deficit also results in hemoconcentration, increasing the viscosity of the blood and predisposing the patient to thrombosis.

Imagine the blood vessels as a tightly sealed garden hose filled with water. After a burn, the hose develops tiny holes (increased capillary permeability), and water (fluid and proteins) leaks into the surrounding soil (tissues). This leakage leads to less water remaining inside the hose (vascular compartment), making it difficult to deliver water (nutrients and oxygen) effectively.

It is critical to monitor fluid balance, prevent complications, and maintain adequate organ perfusion during this period.

• Administer fluid resuscitation, typically using the Parkland formula, to restore intravascular volume and prevent shock.
• Closely monitor urine output as an indicator of renal perfusion and fluid status (target: 30-50 mL/hour).
• Assess for signs of hypovolemic shock, such as tachycardia, hypotension, and altered mental status.
• Monitor electrolyte levels, as sodium and potassium imbalances are common during this phase.
• Implement measures to minimize edema, such as elevating affected extremities.

✘Incorrect answer options:

An increase in the total volume of intracranial plasma. There is no significant change in intracranial plasma volume associated with burn injuries. Instead, systemic hypovolemia due to fluid shifts is a hallmark of the early post-burn phase.

Excessive renal perfusion leading to diuresis. In the immediate post-burn period, hypovolemia leads to decreased renal perfusion, not excessive perfusion. This can result in oliguria (decreased urine output) or even acute kidney injury if not properly managed.

Fluid shift from the interstitial space into the intravascular space. This process typically occurs during the later "fluid mobilization" phase, after 48-72 hours, as capillary permeability normalizes and fluids are reabsorbed back into the vascular compartment. It is not characteristic of the initial post-burn period.

EXPLANATION

✔Correct answer:

"Apply sunscreen every day, even when it is cloudy." The most effective way to minimize sun-related skin damage is to apply sunscreen daily, even on cloudy days. UV rays, particularly UVA and UVB, can penetrate clouds and cause skin damage even when the sun isn’t visible. This daily habit protects the skin from both short-term effects, like sunburn, and long-term effects, such as premature aging, hyperpigmentation, and an increased risk of skin cancer. It is critical to use a broad-spectrum sunscreen with an appropriate Sun Protection Factor (SPF) of 30 or higher, as it blocks both UVA and UVB rays.

Think of sunscreen as a raincoat for your skin. Just as rain can still get you wet on a cloudy day, UV rays can still harm your skin even when the sun isn’t shining. A daily layer of sunscreen ensures protection, rain or shine!

Nurse Evans should emphasize these important points for effective sun protection and prevention of skin damage:

• Use broad-spectrum sunscreen: Ensure the sunscreen protects against both UVA (aging rays) and UVB (burning rays).
• Reapply frequently: Sunscreen should be reapplied every two hours, especially after swimming, sweating, or towel drying.
• Cover exposed areas: Pay special attention to often-forgotten spots like the ears, back of the neck, and tops of the feet.
• Combine protection methods: In addition to sunscreen, wear protective clothing, hats, and sunglasses to shield your skin from UV exposure.
• Limit peak sun exposure: Encourage patients to seek shade and avoid direct sun exposure, especially during peak hours from 10:00 AM to 4:00 PM.

✘Incorrect answer options:

"Limit sun exposure between 1:00 PM and 4:00 PM, when the sun's rays are most intense." The peak hours for UV intensity are 10:00 AM to 4:00 PM, not starting at 1:00 PM. While avoiding the sun during these times is helpful, it is not always practical. Additionally, UV rays can still cause skin damage outside of these hours, so relying solely on avoiding sun exposure is not sufficient.

"Use a sunscreen product with a sun protection factor (SPF) of 6 or higher." An SPF of 6 provides inadequate protection. The American Academy of Dermatology recommends using a sunscreen with an SPF of 30 or higher for effective protection against harmful UV rays.

"When at the beach, stay in shaded areas to avoid sunburn." While staying in the shade can help reduce direct UV exposure, it does not fully prevent skin damage. UV rays can reflect off surfaces like sand and water, still causing harm. Comprehensive sun protection, including sunscreen and protective clothing, is necessary even in shaded areas.

EXPLANATION

✔Correct answer:

Serum potassium 7.5 mEq/L. A serum potassium level of 7.5 mEq/L indicates severe hyperkalemia, which is a life-threatening electrolyte imbalance requiring immediate intervention. In the emergent phase of a burn injury, potassium levels can rise dangerously high due to massive cell destruction (cell lysis), which releases intracellular potassium into the extracellular space. Hyperkalemia can lead to critical complications such as cardiac arrhythmias, including ventricular fibrillation or cardiac arrest, making it the most urgent abnormality to report.

Key considerations for hyperkalemia:  

• Normal potassium range: 3.5-5.0 mEq/L.
• Critical threshold: Levels above 6.0 mEq/L can cause significant cardiac disturbances.
• Interventions: The healthcare provider may order immediate interventions such as administration of calcium gluconate (to stabilize the heart), insulin with glucose (to drive potassium back into cells), or dialysis in severe cases.

Think of the heart as a computer, and potassium as the electricity powering it. Too much electricity (hyperkalemia) can "short-circuit" the computer, causing it to malfunction (arrhythmias). Immediate action is needed to protect the system.

In the emergent phase, careful monitoring of electrolyte levels is critical. For hyperkalemia:

• Monitor cardiac status: Place the patient on continuous cardiac monitoring to detect arrhythmias.
• Administer prescribed medications: This may include calcium gluconate, sodium bicarbonate, insulin with glucose, or potassium-binding agents like sodium polystyrene sulfonate (Kayexalate).
• Restrict potassium intake: Ensure that IV fluids or nutritional support does not exacerbate hyperkalemia.
• Address underlying cause: In burn patients, hyperkalemia results from tissue damage, so controlling the burn-related complications is key.

✘Incorrect answer options:

Serum sodium 131 mEq/L. A sodium level of 131 mEq/L reflects hyponatremia, which is common during the emergent phase of burns due to fluid shifts and losses. While it requires monitoring and management, mild hyponatremia is not as immediately life-threatening as hyperkalemia.

Arterial pH 7.32. An arterial pH of 7.32 indicates mild acidosis, which is expected during the emergent phase of burns due to hypovolemia and the body’s stress response. Although acidosis requires correction (e.g., fluid resuscitation), it does not take precedence over life-threatening hyperkalemia.

Hematocrit 52%. An elevated hematocrit is common after major burns due to hemoconcentration caused by significant fluid loss and plasma shifts. While it indicates hypovolemia and the need for aggressive fluid resuscitation, it does not pose the same immediate threat as hyperkalemia.

EXPLANATION

✔Correct answer:

Immediately loosen the neck dressing. The priority intervention is to immediately loosen the neck dressing if it is causing or contributing to respiratory distress. Tight dressings around the neck can impair breathing by compressing the trachea, restricting neck movement, or causing vascular compromise that can lead to airway swelling. In the context of burns, swelling and edema can increase rapidly, further compromising the airway. Loosening the dressing helps relieve the pressure and allows the airway to remain open while additional interventions are considered.

In patients with burn injuries near the neck, airway compromise is a significant risk due to both external compression (e.g., tight dressings) and internal swelling from inhalation injury or fluid shifts. Rapid action to relieve pressure can be lifesaving.

Imagine wearing a scarf that’s tied too tightly, making it hard to breathe. The first step is to loosen the scarf to relieve pressure and restore airflow.

After loosening the dressing, Nurse Lin should immediately assess and manage the patient's airway and respiratory status.

• Monitor respiratory status: Assess breathing rate, depth, and effort. Check for additional signs of airway obstruction, such as stridor, hoarseness, or cyanosis.
• Provide supplemental oxygen: Administer oxygen if the patient continues to show signs of respiratory distress after the dressing is loosened.
• Notify the provider promptly: Inform the healthcare provider of the situation and prepare for potential advanced airway interventions, such as intubation or a tracheostomy, if needed.
• Assess for other causes of distress: Evaluate for contributing factors such as inhalation injury, eschar formation, or fluid overload.
• Reapply the dressing if necessary: Once the airway is stabilized, reapply a looser dressing to protect the wound and prevent further complications.

✘Incorrect answer options:

Administer supplemental oxygen. While administering oxygen is appropriate for respiratory distress, it is not the first intervention in this situation. If the dressing is causing physical airway obstruction, oxygen alone will not resolve the underlying issue. The dressing must be loosened immediately to restore adequate airflow.

Activate the emergency response team. Activating the emergency response team may be appropriate if loosening the dressing does not resolve the respiratory distress or if the patient's condition worsens. However, loosening the dressing should be done immediately before escalating the situation, as it may quickly resolve the issue.

Document the observation and continue monitoring. Documentation is important but is not the priority intervention. Simply monitoring the situation without taking action could result in rapid airway compromise and potentially life-threatening consequences.

EXPLANATION

✔Correct answer:

New onset of hoarseness. The new onset of hoarseness in a patient with extensive burns is a critical finding that requires immediate notification of the healthcare provider because it may indicate impending airway compromise. Hoarseness is an early sign of inhalation injury, which occurs when a patient inhales smoke, hot air, or toxic fumes during a burn event. Inhalation injury can cause airway edema, laryngeal swelling, or respiratory distress, all of which can rapidly progress to complete airway obstruction.

Patients with large burns (e.g., 60% TBSA) are at higher risk for inhalation injuries, particularly if the burn incident occurred in an enclosed space or involved smoke exposure. Early intervention, such as intubation, may be necessary to secure the airway before edema makes intubation difficult or impossible.

Think of the airway like a tunnel. Hoarseness is like hearing echoes of a small blockage in the tunnel, warning you that it might soon collapse. Immediate action is needed to keep the tunnel open.

Nurse Riley should take immediate actions to address the risk of airway compromise:

• Notify the provider immediately: Report signs of hoarseness, stridor, wheezing, or any respiratory difficulty.
• Anticipate airway management: Prepare for intubation or other airway support measures if swelling progresses.
• Monitor for other signs of inhalation injury: Check for soot around the mouth or nose, singed nasal hairs, or carbonaceous sputum (black, soot-containing sputum).
• Administer supplemental oxygen: Maintain oxygenation while preparing for further interventions.
• Collaborate with respiratory therapy: Ensure timely interventions to prevent airway obstruction and support ventilation.

✘Incorrect answer options:

Reports of intense thirst. Intense thirst is a common finding in burn patients due to fluid shifts and dehydration during the emergent phase of burns. While this symptom warrants attention and appropriate fluid replacement, it is not as urgent or life-threatening as a potential airway compromise.

Reports of moderate to severe pain. Pain is expected in patients with partial-thickness burns, as nerve endings in the dermis are intact. Although pain management is important, it does not take priority over addressing signs of airway compromise.

Urine output of 70 mL in the first hour. A urine output of 70 mL in the first hour is within the acceptable range for burn patients, as the target urine output is 30-50 mL/hour. This finding indicates adequate fluid resuscitation and does not require immediate intervention.

EXPLANATION

✔Correct answer:

The patient's circulatory status. During the acute phase of burn management, the nurse's top priority is to monitor and assess the patient's circulatory status. This phase begins after the emergent phase, typically 48-72 hours after the injury, when fluid shifts start to stabilize, and the focus shifts to wound healing and preventing complications such as infection, organ dysfunction, or tissue ischemia. Circulatory assessment remains critical, especially in burns affecting extremities or circumferential burns, as impaired circulation due to eschar formation, swelling, or compartment syndrome can threaten limb viability.

Assessing circulatory status involves checking distal pulses, skin temperature, capillary refill, and signs of adequate perfusion to ensure blood flow is maintained. Compromised circulation could require urgent interventions such as escharotomy to relieve pressure and restore adequate perfusion.

Think of circulation like water flowing through pipes. If a blockage (swelling or tight eschar) occurs, the flow (blood) will stop, and the pipes (tissues) downstream will be damaged. Ensuring proper flow is critical to prevent tissue death.

Nurse Reyes should prioritize interventions that ensure adequate circulatory status:

• Frequent neurovascular checks: Assess for diminished or absent distal pulses, delayed capillary refill, and changes in skin color or temperature.
• Monitor for compartment syndrome: Be alert for symptoms such as increasing pain, tightness, or loss of sensation in the affected area, as this may require immediate escharotomy.
• Evaluate for fluid overload or hypovolemia: Monitor for signs of fluid imbalance, as the acute phase may still involve fluid resuscitation and ongoing stabilization of blood volume.
• Promote mobility when possible: Encourage active or passive range-of-motion exercises to improve circulation and prevent stiffness.
• Collaborate with the healthcare team: Notify the provider promptly if circulatory compromise is detected and assist with interventions such as escharotomy or advanced wound care.

✘Incorrect answer options:

The patient's lifestyle. While understanding the patient's lifestyle is important for long-term recovery and rehabilitation planning, it is not a priority during the acute phase when the primary focus is on stabilizing physiological systems and preventing complications.

The patient's alcohol consumption. Although alcohol consumption may impact wound healing and nutritional needs, it is not a critical focus during the acute phase of burn management. Addressing substance use can be prioritized during the rehabilitative phase.

The patient's tobacco use. Tobacco use can impair wound healing due to its effects on circulation and oxygenation, but this is not the immediate priority during the acute phase. Circulatory status takes precedence to prevent critical complications such as ischemia or tissue necrosis.

EXPLANATION

✔Correct answer:

Hemoglobin S electrophoresis. In African American patients, hemoglobin S electrophoresis is particularly important when assessing for the presence of sickle cell trait or sickle cell disease. Individuals with these conditions are at higher risk for complications such as impaired oxygen transport, poor wound healing, or vaso-occlusive crises, especially during times of significant physiological stress, such as burn injuries. Hypoxia, dehydration, and infection—common complications in burn patients—can trigger a sickling crisis in patients with sickle cell trait or disease, further complicating recovery. Identifying hemoglobin S early can guide hydration strategies, oxygen therapy, and other interventions to prevent crises and optimize the patient's outcomes.

Think of hemoglobin as delivery trucks transporting oxygen. In sickle cell conditions, some trucks break down under stress, causing traffic jams (blockages). Testing for hemoglobin S ensures the healthcare team is aware of potential breakdowns so they can keep the "roads" clear.

Nurse Thompson should advocate for hemoglobin S electrophoresis testing and take the following steps:

• Monitor for signs of sickling crises: Watch for pain, swelling, or signs of tissue ischemia, which may indicate vaso-occlusion.
• Maintain adequate hydration: Ensure IV fluids are administered to prevent dehydration, which can trigger sickling.
• Administer oxygen as needed: Support oxygenation to prevent hypoxia, another major trigger for sickle cell crises.
• Collaborate with the healthcare team: Involve hematology specialists if sickle cell disease or trait is identified, and plan interventions to manage or prevent complications.
• Educate the patient and family: Explain the importance of hydration, avoiding stressors, and managing pain to prevent complications related to sickle cell conditions.

✘Incorrect answer options:

Total protein level. While total protein is relevant for assessing nutritional status and wound healing, it is not specific to genetic conditions like sickle cell disease. Burn patients may require protein level monitoring, but this is not prioritized for African American patients due to genetic factors.

Tissue typing for HLA antigens. Tissue typing is used for organ and tissue transplantation and is unrelated to burn management or genetic risks specific to African American populations.

Prostate-specific antigen (PSA) level. PSA testing is used to screen for prostate cancer in male patients, particularly those over 50 years of age. While African American males are at higher risk for prostate cancer, this test is unrelated to the immediate management of burn injuries.

EXPLANATION

✔Correct answer:

Immature neutrophils (bands) outnumbering mature neutrophils (segmented neutrophils or "segs"). A finding of immature neutrophils (bands) outnumbering mature neutrophils (segmented neutrophils, or "segs") is referred to as a "left shift" in the white blood cell differential. This phenomenon occurs when the body responds to a severe infection or inflammation, such as in sepsis. The bone marrow releases an increased number of immature neutrophils (bands) into the bloodstream to compensate for the heightened demand for immune response.

In a burn patient, a left shift is particularly concerning because burns compromise the immune system and serve as a fertile ground for infections due to the loss of the skin barrier, necrotic tissue, and invasive medical interventions. When coupled with other clinical signs (e.g., fever, tachycardia, hypotension), a left shift strongly suggests the potential for sepsis.

During a severe infection or systemic inflammatory response, neutrophils are rapidly consumed at the site of infection. The bone marrow accelerates neutrophil production and releases immature forms (bands) before they fully mature. Normally, segmented neutrophils are the predominant type of neutrophil in circulation, and bands make up only 3-5% of the total. When bands outnumber segs, it signals that the body is under significant stress, potentially indicative of sepsis.

Think of the immune system like an army. The "experienced soldiers" (mature neutrophils) are usually deployed first to fight infection. In cases of severe infection (like sepsis), the "rookies" (immature neutrophils) are sent to the battlefield because the experienced soldiers are depleted. A higher number of rookies than veterans signals an urgent and overwhelming situation.

Recognizing a left shift is critical for initiating timely interventions to prevent the progression of sepsis.

• Assess for clinical signs of sepsis, such as fever, altered mental status, tachycardia, hypotension, and decreased urine output.
• Ensure blood cultures and other relevant cultures are obtained to identify the source of infection.
• Anticipate and administer broad-spectrum antibiotics as prescribed, followed by pathogen-specific therapy once cultures are available.
• Monitor trends in laboratory values, including lactate levels, procalcitonin, and white blood cell counts.
• Support organ perfusion through fluid resuscitation, vasopressors, and oxygen therapy as necessary.

✘Incorrect answer options:

A total white blood cell count of 9,000/mm³. A total WBC count of 9,000/mm³ is within the normal range (4,500–11,000/mm³) and does not suggest sepsis. It is the differential and the presence of immature neutrophils (bands) that are more specific indicators of infection severity.

Lymphocytes being more numerous than basophils. This finding is not clinically significant in the context of sepsis. Lymphocytes are typically more numerous than basophils under normal circumstances and do not provide specific information about the presence of sepsis.

A monocyte count of 1,800/mm³. While monocytes can increase during chronic infections and inflammatory states, they are not the primary cells involved in the acute response to bacterial infections. An isolated rise in monocytes is not specific for sepsis and is less clinically relevant compared to the presence of a left shift in neutrophils.

EXPLANATION

✔Correct answer:

Diminished or absent distal pulses and delayed capillary refill in the fingers. Diminished or absent distal pulses and delayed capillary refill are critical signs of compromised circulation due to circumferential burns. Full-thickness burns can form eschar (a thick, inelastic, leathery layer of dead tissue) that acts like a tight band around the limb. This eschar restricts blood flow and increases the risk of compartment syndrome, a life-threatening condition caused by pressure buildup that impairs circulation and nerve function. Escharotomy, a surgical procedure to cut through the eschar, is required to relieve pressure, restore circulation, and prevent tissue necrosis.

Key clinical signs indicating the need for an escharotomy include:

• Diminished or absent distal pulses.
• Delayed capillary refill.
• Cool, pale, or cyanotic extremities.
• Increasing pain or tightness despite adequate analgesia.
• Progressive numbness, tingling, or paresthesia.

Without timely intervention, ischemia, tissue necrosis, and loss of the limb may occur.

Imagine a rubber band tightly wrapped around your arm, cutting off blood flow to your hand. Eschar acts similarly to the rubber band, and an escharotomy is like snipping the band to restore circulation and relieve pressure.

Nurse Sanchez should monitor closely for signs of compromised circulation and take appropriate actions to address the patient’s condition:

• Assess neurovascular status frequently: Check distal pulses, skin temperature, capillary refill, color, and sensation regularly.
• Notify the provider immediately: Report signs of circulation impairment or compartment syndrome promptly for evaluation and intervention.
• Prepare for escharotomy: Assist in setting up the procedure by ensuring sterile supplies and providing emotional support to the patient.
• Monitor after escharotomy: Continue to assess circulation, monitor for bleeding, and evaluate the effectiveness of the procedure.
• Educate the patient: Explain the purpose of the escharotomy and the importance of ongoing monitoring to prevent complications.

✘Incorrect answer options:

The burn extends through all layers of the skin (full thickness). While full-thickness burns often create eschar, the need for escharotomy is determined by signs of circulatory compromise, not the depth of the burn itself. Full-thickness burns do not automatically indicate the need for this intervention.

The patient has limited range of motion, specifically difficulty with pronation and supination. Restricted range of motion is common in burn injuries due to pain, edema, or scarring, but it is not an immediate indication for escharotomy unless it is accompanied by signs of vascular compromise, such as absent pulses or ischemia.

The patient reports altered sensation, unable to differentiate between sharp and dull touch. Altered sensation (e.g., numbness or inability to feel sharp/dull touch) may indicate nerve damage or pressure on nerves. However, escharotomy is indicated only when altered sensation occurs with vascular compromise (e.g., absent pulses, cyanosis). Alone, altered sensation does not justify the procedure.

EXPLANATION

✔Correct answer:

“Since the transplanted skin is from my own body, there’s no possibility of rejection.” This statement by Ms. Rodriguez indicates a misunderstanding of the type of graft used in her procedure. An allograft involves using skin from a donor (another person), not from the patient’s own body (which would be an autograft). Because the skin comes from another individual, there is a possibility of rejection unless the allograft is used as a temporary graft to cover wounds and promote healing until autografting or another permanent solution can be performed. The immune system may recognize the donor skin as foreign and mount a response, which is why allografts are typically temporary and replaced with autografts or synthetic grafts later.

Think of an allograft like borrowing a jacket from a friend—it can protect you temporarily, but it doesn’t fit perfectly, and eventually, you’ll need your own jacket to wear permanently. Similarly, an allograft provides temporary coverage, but it is not a long-term solution due to potential rejection.

Nurse Evans should clarify the difference between an allograft and an autograft to ensure Ms. Rodriguez understands the nature of her procedure and its implications:

• Explain the role of allografts: Emphasize that allografts are typically used as temporary coverage to protect the wound, reduce fluid loss, and prevent infection until a permanent graft (e.g., autograft) can be applied.
• Discuss the risk of rejection: Educate the patient about the immune response and explain that rejection is a possibility with allografts, which is why they are not permanent solutions.
• Provide information on long-term plans: Inform Ms. Rodriguez that the next steps may include autografting or other procedures to provide permanent skin coverage. Reassure her that donor sites (if used in autografting) will heal over time with proper care.
• Review graft care instructions: Reinforce proper wound care, infection prevention strategies, and follow-up expectations to ensure optimal outcomes after the procedure.

✘Incorrect answer options:

“For the initial postoperative period, the areas where the skin was taken will be uncomfortable.” This statement is accurate but applies to autografts (using the patient’s own skin). It does not conflict with the explanation of allografts. However, Nurse Evans should confirm whether Ms. Rodriguez had an autograft in addition to the allograft procedure.

“I understand that there will be some scarring at the donor sites.” This statement is true and reflects an understanding of autografting, where skin is harvested from donor sites on the patient’s body. It does not directly apply to allografts but indicates accurate knowledge of autograft procedures if both were discussed.

“After the grafting is finished, my risk of infection will be the same as before I was burned.” This is incorrect because burn patients have a heightened risk of infection due to compromised skin integrity. Even after grafting, the risk of infection remains higher than baseline until the skin barrier is fully healed. However, it does not directly indicate a misunderstanding of allografting, so it is less relevant than the correct answer.

EXPLANATION

✔Correct answer:

A myocardial infarction (MI) one year ago. A history of myocardial infarction (MI) or any cardiac condition warrants special consideration and adjustment to the standard fluid resuscitation protocol. Burn patients require significant fluid replacement, especially during the emergent phase, to prevent hypovolemic shock due to extensive fluid shifts. However, excessive fluid administration in patients with a history of MI or compromised cardiac function can overwhelm the heart's ability to pump effectively, leading to fluid overload, pulmonary edema, or congestive heart failure (CHF).

In such cases, fluid resuscitation must be carefully monitored and adjusted based on the patient’s cardiac output, central venous pressure (CVP), and overall tolerance to the fluid load. Close hemodynamic monitoring is critical to balancing adequate perfusion with preventing cardiac complications.

Think of a heart with a history of MI like a weakened pump. If too much fluid is added too quickly, the pump struggles and the excess spills over, just like fluid backing up into the lungs during overload.

Nurse Riley should take the following steps when managing fluid resuscitation in a burn patient with a cardiac history:

• Adjust fluid resuscitation protocol: Use a modified fluid resuscitation approach (e.g., reducing the rate or volume of fluids) under the provider’s direction.
• Monitor for signs of fluid overload: Watch for dyspnea, crackles on auscultation, jugular vein distension, or peripheral edema.
• Conduct hemodynamic monitoring: Use tools such as CVP measurement or echocardiography to assess fluid balance and cardiac function.
• Administer diuretics if needed: If signs of fluid overload develop, diuretics may be prescribed to manage excess fluid while maintaining adequate perfusion.
• Collaborate with the interdisciplinary team: Work closely with cardiologists, intensivists, or burn specialists to tailor the fluid resuscitation plan to the patient’s cardiac tolerance.

✘Incorrect answer options:

A history of seasonal asthma. Seasonal asthma primarily affects the respiratory system and does not typically impact fluid resuscitation protocols unless the patient is experiencing an active asthma exacerbation. While respiratory status should be monitored, asthma does not necessitate fluid adjustment.

A diagnosis of Hepatitis B ten years prior. A past diagnosis of Hepatitis B does not necessarily affect the liver’s current ability to tolerate fluid resuscitation unless there is evidence of chronic liver disease or cirrhosis. If the liver function is normal, fluid resuscitation adjustments are not typically required.

A history of kidney stones within the past six months. While kidney stones can cause localized kidney damage or obstruction, they do not usually impair overall kidney function or fluid management. However, active renal impairment (e.g., decreased glomerular filtration rate or oliguria) would necessitate careful monitoring of fluid resuscitation.

EXPLANATION

✔Correct answer:

Related to circumferential eschar. The most appropriate "related to" phrase for a nursing diagnosis of Impaired Physical Mobility in a patient with full-thickness burns on both lower legs is "related to circumferential eschar." Full-thickness burns result in the formation of eschar, which is a thick, inelastic layer of dead tissue that can surround a limb (circumferential eschar). When eschar forms around the lower legs, it can restrict mobility by causing skin tightening, reduced joint movement, and pain. Additionally, circumferential eschar can compromise circulation, leading to further complications like compartment syndrome, which further limits mobility.

Imagine trying to move while wearing a very tight cast around your leg. The cast limits your ability to bend or stretch, just like eschar limits mobility in a burn injury.

Circumferential eschar acts like a tight band around the limb, potentially compressing underlying tissues, blood vessels, and nerves. This not only restricts mobility but can also cause complications like ischemia, which might require escharotomy (a surgical procedure to release the pressure and restore circulation).

To address "Impaired Physical Mobility" related to circumferential eschar, Nurse Jenna should focus on the following:

• Monitor circulation closely: Check for signs of impaired perfusion (e.g., decreased pulses, cool extremities, delayed capillary refill) to detect early signs of compartment syndrome.
• Positioning and mobility support: Use splints and ensure proper alignment to maintain joint function and prevent contractures.
• Physical therapy: Collaborate with physical and occupational therapists for range-of-motion (ROM) exercises to preserve joint flexibility and prevent stiffness.
• Pain management: Administer prescribed analgesics before movement or dressing changes to encourage mobility despite discomfort.
• Surgical intervention if needed: Anticipate and prepare the patient for escharotomy if circumferential eschar compromises mobility or circulation.

✘Incorrect answer options:

Related to fat emboli. Fat emboli are associated with long bone fractures or orthopedic injuries, not with burns. This is not relevant to the impaired mobility caused by circumferential eschar.

Related to infection. While infection can occur in burn wounds, it does not directly impair mobility in the same way circumferential eschar does. Infection may cause systemic effects like fever or sepsis, but it is not the primary factor restricting joint movement in this scenario.

Related to femoral artery occlusion. A femoral artery occlusion is not typically caused by burn injuries. While circumferential eschar can impair peripheral circulation, it does not lead to a complete occlusion of a major artery like the femoral artery. This is not the correct rationale for the patient's impaired mobility.

EXPLANATION

✔Correct answer:

Consistent urine output exceeding 100 mL/hour. In burn patients undergoing fluid resuscitation, the most critical indicator that fluid therapy is effective is adequate urine output, as it reflects both sufficient fluid replacement and effective kidney perfusion. For a 70 kg patient, the target urine output is typically 0.5-1 mL/kg/hour, which would equal 35-70 mL/hour. A consistent urine output exceeding 100 mL/hour suggests that the patient is receiving enough fluids to maintain adequate circulation and renal function, which are primary goals during the emergent phase of burn care.

Fluid resuscitation is necessary to combat hypovolemia caused by fluid shifts and plasma loss following burns. Ensuring that the kidneys are producing urine confirms that the circulating blood volume is adequate to perfuse vital organs, including the kidneys. Monitoring urine output is a simple, non-invasive, and highly effective method of assessing the success of fluid resuscitation.

Think of the body like a sponge that has lost water after being burned. Fluid resuscitation "refills the sponge," and the appearance of steady drops (urine output) indicates that the sponge is now sufficiently hydrated.

Nurse Kelly should implement the following to monitor and adjust fluid resuscitation as needed:

• Frequent urine output monitoring: Use a Foley catheter to measure hourly urine output accurately and ensure it remains within the target range (0.5-1 mL/kg/hour).
• Assess for signs of over-resuscitation: Monitor for increased respiratory rate, crackles in the lungs, or edema, which may indicate fluid overload.
• Adjust fluids as prescribed: Collaborate with the healthcare team to adjust fluid rates based on urine output, hemodynamic stability, and laboratory findings (e.g., serum electrolytes, hematocrit).
• Monitor vital signs: Track blood pressure and heart rate to ensure adequate perfusion and circulation.
• Assess for electrolyte imbalances: Monitor potassium and sodium levels, as fluid shifts and resuscitation can lead to hyperkalemia, hypokalemia, or hyponatremia.

✘Incorrect answer options:

A weight increase of 2 kg within a 24-hour period. A weight increase could indicate fluid retention, but it does not confirm adequate perfusion or organ function. Additionally, weight gain may reflect over-resuscitation, leading to complications like pulmonary edema.

Body temperature readings consistently within normal parameters. Maintaining a normal body temperature is important for burn patients, but it does not specifically indicate effective fluid resuscitation. Burn patients often require external warming devices to combat hypothermia caused by loss of skin and fluids.

A stable electrocardiogram (ECG) without any arrhythmias. A stable ECG is desirable but not directly related to the adequacy of fluid resuscitation. Arrhythmias in burn patients are more commonly caused by electrolyte imbalances, particularly hyperkalemia or hypokalemia, rather than inadequate fluids.

EXPLANATION

✔Correct answer:

Keeping the hip extended with the leg flat. To prevent contractures and preserve joint function during the healing process after a severe burn, it is crucial to position the affected limb in a neutral or extended position. Burns around the right hip place Ms. Johnson at significant risk for developing hip flexion contractures, which occur when scar tissue tightens and restricts mobility, leading to permanent deformity.

Keeping the hip extended (with the leg flat) helps maintain proper alignment, stretch healing tissues, and reduce the risk of contractures. Immobilizing the joint in a flexed position (such as 30 or 90 degrees of flexion) would promote contracture development.

Imagine trying to keep a rubber band straight while it's drying out. If you keep it bent, it will dry in that position and lose its flexibility. Similarly, positioning the hip extended ensures the healing tissues remain flexible and functional.

Nurse Kelly should educate Ms. Johnson on proper positioning and emphasize interventions to promote optimal joint function.

• Encourage correct positioning: Keep the hip extended (neutral position) with the leg flat. Use positioning aids, such as splints, if necessary, to maintain proper alignment.
• Monitor for early signs of contractures: Watch for reduced range of motion or tightness around the hip joint during healing.
• Incorporate physical therapy: Collaborate with physical therapists to implement an exercise program that includes stretching, range-of-motion exercises, and strengthening to prevent contractures.
• Educate on consistent adherence: Stress the importance of maintaining the recommended position, especially when sitting, to avoid prolonged periods of hip flexion.
• Scar management: Use compression garments or other measures to reduce hypertrophic scarring, which can contribute to contracture formation.

✘Incorrect answer options:

Keeping the hip flexed at 30 degrees with the knee straight. While keeping the knee straight may reduce knee flexion contractures, maintaining the hip in 30 degrees of flexion places the joint in a suboptimal position for healing. Prolonged hip flexion increases the risk of contracture.

Maintaining both the hip and knee flexed at 90 degrees. This position promotes contracture formation in both the hip and knee. Flexed positions are especially detrimental for joints as they encourage scarring and loss of range of motion.

Maximizing flexion at the hip, knee, and ankle joints. Maximizing flexion across multiple joints is counterproductive. It significantly increases the risk of contractures and functional impairments, requiring aggressive rehabilitation or surgical correction later.

EXPLANATION

✔Correct answer:

Encouraging neck hyperextension using a rolled towel under the shoulders. The most crucial intervention for minimizing the risk of contractures in a patient with a deep partial-thickness burn on the posterior neck is encouraging neck hyperextension. Burns in this area are at high risk for developing flexion contractures due to the natural healing process, which involves scar tissue tightening and shortening over time. Positioning the neck in hyperextension counteracts the skin's tendency to contract and ensures that functional range of motion is preserved during the healing process. Using a rolled towel under the shoulders helps maintain this hyperextended position effectively.

Flexion contractures in the neck can lead to long-term mobility issues, impaired functional ability, and cosmetic concerns. Early and consistent positioning interventions during the acute phase of recovery are essential to prevent these complications.

Imagine a rubber band stretched over time to keep it flexible. If you let the rubber band stay curled or tight, it will harden and lose its ability to stretch. Similarly, the burned neck tissue naturally tries to contract as it heals, but by positioning the neck in hyperextension, you’re "stretching the rubber band" to ensure the tissue remains flexible and functional.

Nurse Singh should focus on strategies to prevent contractures and maintain optimal neck mobility:

• Encourage and maintain hyperextension: Position the neck in hyperextension with a rolled towel under the shoulders or a cervical collar as prescribed.
• Incorporate range-of-motion exercises: Teach and assist the patient with active or passive exercises to maintain neck flexibility and prevent stiffness.
• Educate the patient: Explain the importance of hyperextension positioning, even if it is uncomfortable, and encourage adherence to the care plan.
• Monitor for signs of contracture formation: Assess for decreased range of motion, tightening of the burn area, or difficulty maintaining the hyperextended position.
• Collaborate with physical therapy: Involve physical therapists early in the care plan to design a comprehensive exercise and positioning program.

✘Incorrect answer options:

Positioning the neck in flexion to reduce strain on the burn area. Flexion positioning is contraindicated in this case because it promotes the development of flexion contractures, which limit the patient’s ability to extend their neck and lead to permanent stiffness.

Applying moist dressings and avoiding neck movement. While proper wound care (e.g., applying moist dressings) is important for healing, avoiding neck movement increases the risk of stiffness and contracture formation. Movement and hyperextension are necessary to maintain functional range of motion.

Supporting the neck with a pillow to maintain comfort. Using a pillow to support the neck in a flexed or neutral position promotes flexion contractures in patients with burns on the posterior neck. Comfort should be balanced with positioning that prevents complications, even if it causes temporary discomfort.

EXPLANATION

✔Correct answer:

During the fluid remobilization phase. Hypokalemia (low serum potassium levels) is most likely to develop during the fluid remobilization phase, which typically begins 48-72 hours after the initial burn injury. In this phase, fluid shifts from the interstitial space back into the intravascular space as capillary integrity is restored. During this process, potassium that had leaked out of the cells into the extracellular space is excreted through the urine due to diuresis, leading to a potential drop in serum potassium levels. This is in contrast to the earlier phase, when hyperkalemia is more common due to massive cell destruction and the release of intracellular potassium.

Hypokalemia during the fluid remobilization phase can result in complications such as muscle weakness, cardiac arrhythmias, and impaired wound healing, making close monitoring of serum potassium levels critical.

Think of potassium like water in a sponge. Initially, the sponge (cells) releases potassium (hyperkalemia). As the water (fluid) returns to the bloodstream, the sponge dries out and loses more potassium, leading to hypokalemia during the remobilization phase.

Nurse Davis should implement the following measures to address the risk of hypokalemia during the fluid remobilization phase:

• Monitor serum potassium levels: Check laboratory results frequently to identify trends and detect hypokalemia early.
• Assess for symptoms of hypokalemia: Look for signs such as muscle weakness, fatigue, decreased reflexes, and changes in cardiac rhythms (e.g., flattened T waves or U waves on ECG).
• Administer potassium supplements as prescribed: If potassium levels are low, administer IV or oral potassium as ordered, ensuring safe administration (e.g., IV potassium must be diluted and infused slowly).
• Monitor cardiac status: Use continuous cardiac monitoring to detect arrhythmias caused by electrolyte imbalances.
• Collaborate with the healthcare team: Communicate potassium trends and ensure adjustments are made to fluid or electrolyte management as needed.

✘Incorrect answer options:

Immediately after the initial injury. Immediately following the burn injury, hyperkalemia (not hypokalemia) is more common due to the release of intracellular potassium caused by massive cell destruction (lysis). This is part of the body’s initial response to the burn injury.

During the period of fluid shift. During the fluid shift phase (the first 24-48 hours post-burn), potassium levels may remain elevated due to ongoing cellular destruction and the movement of potassium into the extracellular space. Hypokalemia is unlikely to occur during this period.

During the later stages of the acute phase. While electrolyte imbalances may still occur later in the acute phase, hypokalemia is most likely during the fluid remobilization phase, not at the later stages of the acute phase when fluid and electrolytes have generally stabilized.

EXPLANATION

✔Correct answer:

Evaluation of heart rate and rhythm. Electrical injuries pose a significant risk to the cardiovascular system because the electrical current can disrupt the heart’s conduction pathways, potentially causing arrhythmias, including ventricular fibrillation, asystole, or other dysrhythmias. The heart's susceptibility to electrical injury makes monitoring the patient’s heart rate and rhythm a priority. Early identification and management of arrhythmias can be life-saving.

Electrical currents can interfere with the heart’s normal electrical signaling. Even low-voltage currents can lead to significant cardiac dysrhythmias, and the risk is higher in injuries with an identifiable entry and exit point, as the current likely passed through the torso, potentially affecting the heart. In addition, cardiac damage may be delayed, requiring continuous monitoring.

Imagine the heart as a carefully timed metronome. If an electrical shock disrupts the metronome, it might stop altogether (asystole) or start ticking erratically (arrhythmias). Monitoring the heart’s "ticking" (rate and rhythm) ensures that any issues are identified and corrected promptly.

Immediate assessment and ongoing monitoring are essential to address cardiovascular complications effectively.

• Connect the patient to continuous cardiac monitoring (e.g., telemetry) upon admission to detect any dysrhythmias.
• Obtain a 12-lead electrocardiogram (ECG) to assess for baseline abnormalities, such as ST changes or arrhythmias.
• Monitor blood pressure and pulse to assess for signs of shock or cardiovascular instability.
• Prepare to administer advanced cardiac life support (ACLS) interventions if life-threatening arrhythmias develop.
• Assess and document peripheral pulses, as vascular damage may occur due to thermal effects of the electrical current.

✘Incorrect answer options:

Assessment of airway patency. While assessing airway patency is a critical step in any trauma scenario, airway compromise is not the most immediate concern in electrical injuries unless there is a burn to the airway (e.g., due to a lightning strike or contact with high-voltage currents). In this scenario, the absence of airway-specific details (e.g., singed nasal hairs, carbonaceous sputum) makes cardiac monitoring the higher priority.

Determination of orientation to time, place, and person. Neurological assessment is important because electrical injuries can cause CNS damage, particularly if the brain is part of the electrical pathway. However, it is not as immediately life-threatening as cardiac dysrhythmias, which can result in sudden death if unaddressed. Once cardiac stability is confirmed, a focused neurological assessment should follow.

Assessment of current range of motion in all extremities. Assessing range of motion is necessary for identifying potential musculoskeletal injuries, such as fractures caused by intense muscle contractions during the electrical shock. However, this is not the most critical or immediate assessment because cardiac complications are life-threatening and require urgent attention.

EXPLANATION

✔Correct answer:

"It reduces stomach acid production to prevent stress ulcers." Cimetidine, an H2 histamine receptor antagonist, reduces the production of stomach acid. In burn patients, the emergent phase is characterized by a high level of physical stress, which can increase the risk of developing Curling’s ulcers, a type of stress-related gastrointestinal ulceration. These ulcers occur due to decreased perfusion to the gastric mucosa and the hypersecretion of stomach acid during the stress response. Administering cimetidine helps protect the gastric mucosa by lowering acid levels, thereby preventing the formation of stress ulcers and reducing the risk of gastrointestinal bleeding.

Think of stomach acid as a "hot liquid" in a cup. If the liquid overflows (excess acid), it can damage the surface (the stomach lining). Cimetidine acts like a lid, keeping the liquid level low and protecting the surface from damage.

When administering cimetidine to burn patients, the nurse should take the following actions:

• Monitor for signs of gastrointestinal bleeding: Check for symptoms such as dark, tarry stools or "coffee ground" emesis, which may indicate bleeding.
• Assess for side effects of cimetidine: Watch for common side effects such as headache, dizziness, or diarrhea.
• Evaluate for continued ulcer prevention needs: Ensure the patient continues appropriate prophylaxis as they progress through recovery, especially if under prolonged stress or critical care.
• Educate the family: Provide reassurance about the medication’s role in preventing ulcers caused by the body's stress response during severe burns.

✘Incorrect answer options:

"It helps increase urine output and protect the kidneys." Cimetidine does not influence urine output or kidney protection. Fluid resuscitation and close monitoring of renal function are key interventions for protecting the kidneys during the emergent phase of a burn injury.

"It stimulates bowel motility and prevents abdominal distention." Cimetidine does not have an effect on bowel motility. Instead, it reduces gastric acid secretion, which is unrelated to abdominal distention or bowel function.

"It prevents fluid loss from the bloodstream and helps avoid shock." Fluid loss and hypovolemic shock in burn patients are managed through fluid resuscitation using formulas like the Parkland formula. Cimetidine does not directly influence fluid balance or prevent shock.

EXPLANATION

✔Correct answer:

It ensures rapid onset of pain relief. In the acute management of burn injuries, rapid pain relief is the priority because burn injuries cause extreme pain that must be addressed immediately to prevent additional stress on the body. Administering morphine via the IV route provides the quickest onset of action compared to other routes, making it ideal in emergencies. Intravenous administration allows the medication to directly enter the bloodstream, bypassing delays associated with absorption through the gastrointestinal tract or muscle tissue, ensuring immediate effectiveness.

In burn patients, other routes, such as intramuscular (IM) or subcutaneous (SQ), are less reliable due to impaired peripheral circulation caused by fluid shifts and hypoperfusion during the emergent phase. Additionally, oral routes are not feasible for patients who may be unable to swallow or have delayed gastric emptying.

Giving morphine intravenously is like taking a direct highway to your destination, ensuring the pain relief is delivered quickly, compared to taking a slower, less efficient route like IM or oral administration.

To ensure safe and effective administration of IV morphine, Nurse Garcia should:

• Assess pain levels: Use a validated pain scale to evaluate the severity of pain before and after administration to monitor the effectiveness of treatment.
• Monitor for adverse effects: Watch for opioid-related side effects, such as respiratory depression, hypotension, nausea, and sedation. Use pulse oximetry to monitor oxygen saturation.
• Administer IV morphine slowly: Follow institutional guidelines to administer IV push opioids over a prescribed time (e.g., 4 mg over 2-3 minutes) to reduce the risk of adverse effects such as hypotension or respiratory depression.
• Reassess frequently: Reassess the patient’s pain level after administration to determine if additional doses or adjustments are necessary, based on the provider's orders.
• Educate the patient and family: Explain the purpose of the medication and address concerns about side effects or potential dependence on opioids.

✘Incorrect answer options:

It minimizes the risk of infection. While IV administration reduces the risk of infection compared to repeated IM or SQ injections, this is not the primary rationale in this acute situation. The focus is on rapid pain relief.

It reduces the likelihood of respiratory depression. Respiratory depression is a potential side effect of opioids, regardless of the route of administration. Administering morphine IV does not decrease this risk but allows for more precise dosing and close monitoring.

It avoids first-pass metabolism in the liver. While IV administration does bypass first-pass metabolism, this is not the most relevant concern in acute burn management. The priority is ensuring a rapid onset of action to control severe pain.

EXPLANATION

✔Correct answer:

Performing hand hygiene before and after patient contact. Hand hygiene is the single most important infection control measure to prevent the spread of microorganisms and reduce cross-contamination. Burn patients are at an elevated risk of infection due to the loss of their protective skin barrier, and proper hand hygiene minimizes the transmission of pathogens during care. It ensures that Nurse Davis is not introducing microorganisms to the patient or transferring pathogens from one part of the body or environment to another.

Hand hygiene includes washing hands with soap and water or using an alcohol-based hand rub before and after any contact with the patient, their wounds, or any equipment used during care. It is a cornerstone of standard precautions and universally effective against a wide range of microorganisms, making it the most paramount intervention for infection control.

Think of your hands as tools that can pick up germs from one area and carry them to another. Handwashing acts like "cleaning the tools" to ensure they don’t spread harmful materials from one spot to another.

To prevent cross-contamination and infection in burn patients, Nurse Davis should employ the following measures:

• Hand hygiene: Always perform handwashing or use an alcohol-based hand rub before and after patient contact or wound care.
• Use appropriate personal protective equipment (PPE): Include gloves, gowns, and masks when necessary to protect both the nurse and the patient from contamination.
• Sterile technique: Ensure strict adherence to sterile technique during wound dressing changes and other procedures involving open wounds.
• Wound care management: Use prescribed topical antibiotics and sterile dressings to reduce microbial growth at the wound site.
• Patient education: Teach the patient and family members about the importance of hand hygiene and wound care to reduce the risk of infection.

✘Incorrect answer options:

Using sterile gloves when removing soiled dressings. While sterile gloves are essential for maintaining asepsis, the gloves themselves cannot completely prevent cross-contamination unless combined with effective hand hygiene. Also, clean (not sterile) gloves are typically sufficient when removing soiled dressings.

Wearing a surgical mask while changing dressings. A surgical mask may help prevent the spread of airborne pathogens from the nurse to the patient, especially for facial burns or in cases of infection control precautions. However, it is not the primary measure to prevent cross-contamination during wound care.

Applying an antibiotic ointment directly to the wound site. Antibiotic ointments can help reduce bacterial load at the wound site but do not prevent cross-contamination or the spread of microorganisms during care. Infection prevention begins with universal precautions like hand hygiene.

EXPLANATION

✔Correct answer:

Document the finding and continue to monitor. A blood glucose level of 90 mg/dL is within the normal range (70-99 mg/dL fasting or <140 mg/dL postprandial) and does not require any immediate intervention. For a patient in the emergent phase of burn injury, close glucose monitoring is standard due to the systemic inflammatory response, increased metabolic demands, and stress-induced hyperglycemia that typically occur. A normal glucose reading in this context is a positive finding and should be documented. Continued monitoring is crucial to detect any deviations from the normal range as the patient's condition evolves. Burn injuries, especially involving >20-30% total body surface area (TBSA), induce a hypermetabolic state, often leading to transient hyperglycemia. However, this glucose level is not concerning and suggests adequate metabolic and hemodynamic management so far.

Think of the blood glucose level as a fuel gauge for the body's energy demands. In this case, the gauge shows the "fuel" is at an appropriate level, so no action is needed other than checking periodically to ensure it stays within range.

Nurse Miller should remain vigilant and monitor the patient closely, as metabolic derangements can occur rapidly in burn patients due to systemic changes.

• Monitor blood glucose trends: Reassess glucose levels regularly as part of burn care to detect any signs of hyperglycemia or hypoglycemia.
• Assess for signs of stress hyperglycemia: Be alert for blood glucose spikes (>140 mg/dL) associated with the systemic response to burns, sepsis, or inadequate insulin regulation.
• Evaluate fluid therapy and nutrition: Ensure IV fluids and nutritional therapy are supporting metabolic needs without contributing to glucose dysregulation.
• Collaborate with the healthcare team: Include endocrinology or nutrition specialists if metabolic derangements arise, such as persistent hyperglycemia.
• Document findings accurately: Normal glucose levels provide important data on the patient's response to treatment and should be documented thoroughly.

✘Incorrect answer options:

Immediately notify the emergency response team. This action is unnecessary for a normal glucose level of 90 mg/dL. The patient is stable in this aspect of their care, and notifying the emergency response team would be inappropriate unless there were other life-threatening concerns.

Inquire about a family history of diabetes mellitus. While hyperglycemia or abnormal glucose metabolism in burn patients might prompt questions about a diabetes history, this is not indicated for a glucose level that is within the normal range. Family history is not relevant in this situation.

Decrease the rate of the intravenous D5LR infusion. Intravenous fluids containing dextrose, such as D5LR (5% dextrose in lactated Ringer's solution), are commonly used in burn patients for fluid resuscitation. The glucose level of 90 mg/dL does not indicate the need to reduce the infusion rate, as it is normal and suggests the dextrose is being metabolized appropriately.

EXPLANATION

✔Correct answer:

The burns are located on the hands and perineum. Burns involving critical areas, such as the hands, face, feet, perineum, or major joints, are associated with a higher risk of complications. These areas are functionally and anatomically significant. For instance:

• Hands: Essential for fine motor skills and daily activities; burns in this area can lead to long-term functional impairment due to scarring and contractures.
• Perineum: Burns in this area pose a high risk for infection due to proximity to urine and feces, which can contaminate the wound and delay healing.

Burns in these regions often require specialized care, such as surgical intervention, grafting, and intensive physical therapy, to prevent permanent disability or functional loss.

Imagine an injury to the hinges of a door (hands and joints)—if not carefully repaired, the door might not open or close properly, just as hands may lose function if burns in this area are not treated appropriately. Similarly, burns on the perineum are like damage near a water pipe—contamination risks are higher and require extra attention.

Nurse Brown should prioritize interventions to minimize complications associated with burns in critical areas.

• Protect against infection: Perform meticulous wound care using sterile techniques, especially for burns near the perineum, to reduce contamination risks.
• Promote functional recovery: Collaborate with physical and occupational therapists to implement early mobility exercises and splinting to prevent contractures in the hands or other joints.
• Provide emotional support: Offer psychological support as burns in visible or sensitive areas can significantly affect body image and emotional well-being.
• Surgical considerations: Prepare the patient for potential skin grafting or reconstructive surgery if the burns in these areas are severe.

✘Incorrect answer options:

The patient is a 26-year-old male. Age is a factor in burn outcomes, but younger adults generally have better physiological reserves and are less likely to experience complications than older adults or children. A 26-year-old male does not inherently have a higher risk based on age or sex alone.

The patient has a history of previous burn injuries. While a history of previous burns may indicate a predisposition to burn injuries or psychological trauma, it does not inherently increase the risk of complications from the current burn injury unless there is a specific residual problem, such as scar contractures.

The burn incident occurred in an open field and involved clothing ignition. While the mechanism of injury (clothing ignition) may cause extensive burns, the environment (open field) reduces the risk of inhalation injury compared to burns in enclosed spaces. Inhalation injury is one of the most significant predictors of poor outcomes, but there is no indication of inhalation injury in this scenario.

EXPLANATION

✔Correct answer:

Superficial partial-thickness burn. The described burn injury—characterized by redness, blistering, and significant pain—indicates a superficial partial-thickness burn. This type of burn involves damage to the epidermis and the upper portion of the dermis (papillary layer), but the deeper layers of the dermis remain intact. Blister formation occurs because of fluid accumulation between the epidermal and dermal layers, and the nerve endings in the dermis remain exposed and sensitive, leading to intense pain.

This classification is supported by the hallmarks of superficial partial-thickness burns:

• Redness (erythema): Caused by increased blood flow to the damaged area.
• Blisters: Indicative of dermal involvement but not extending into deeper structures.
• Pain: Resulting from intact and highly sensitive nerve endings in the dermis.

These burns typically heal in 10-14 days, often without scarring, as long as no infection occurs.

Imagine the skin like a two-layer cake with frosting. A superficial partial-thickness burn damages the frosting (epidermis) and scrapes the top layer of the cake (upper dermis), leaving the deeper parts intact. The damage causes "leakage" (blisters) and makes the exposed top layer very tender (pain).

Prompt and appropriate care is essential to promote healing and prevent complications, such as infection.

• Clean the affected area with sterile, mild solutions to prevent infection and remove debris.
• Apply topical antimicrobial agents (e.g., silver sulfadiazine) as prescribed to prevent wound infection.
• Cover the burn with a sterile, non-adherent dressing to protect the area and reduce further injury.
• Monitor for signs of infection, such as increased redness, swelling, or purulent drainage.
• Provide pain management with prescribed analgesics and non-pharmacological techniques (e.g., distraction or relaxation).
• Educate the patient on proper wound care and the importance of hydration and nutrition for healing.

✘Incorrect answer options:

Superficial burn. Superficial burns (also called first-degree burns) only involve the epidermis. They are characterized by redness and mild pain, but they do not exhibit blistering, which is a key feature of a partial-thickness burn. An example of a superficial burn is a mild sunburn.

Deep partial-thickness burn. Deep partial-thickness burns extend deeper into the dermis (reticular layer), damaging more of the skin’s structures, including sweat glands and hair follicles. These burns are typically less painful than superficial partial-thickness burns because many of the nerve endings are destroyed. The patient's description of "very painful" is more consistent with a superficial partial-thickness burn.

Full-thickness burn. Full-thickness burns (third-degree burns) involve the complete destruction of the epidermis and dermis, and may even extend into subcutaneous tissue, muscle, or bone. These burns are typically painless in the center due to the destruction of nerve endings. The description of blistering, redness, and pain rules out a full-thickness burn.

EXPLANATION

✔Correct answer:

Fluid shift. The patient’s vital signs—hypotension (90/60 mm Hg) and tachycardia (122 beats per minute)—are most likely due to the fluid shift that occurs during the emergent phase of a burn injury. Burns cause significant damage to the skin, which leads to an increase in capillary permeability. This allows plasma and proteins to leak out of the intravascular space and into the interstitial tissues, resulting in hypovolemia (low circulating blood volume).

The fluid shift typically occurs within the first 24-48 hours after a major burn injury and is characterized by:

• Hypovolemia: Loss of intravascular fluid volume leads to hypotension.
• Tachycardia: A compensatory response to maintain cardiac output in the setting of reduced blood volume.
• Hemoconcentration: Elevated hematocrit levels due to plasma loss (not blood loss).

Imagine a water hose with holes in it (representing the damaged capillaries). The water leaks out (fluid shift), reducing the pressure inside the hose (low blood pressure). The heart then pumps faster (tachycardia) to compensate for the loss of fluid volume.

During the emergent phase, Nurse Thompson should prioritize interventions to manage hypovolemia and prevent complications:

• Fluid resuscitation: Administer IV fluids as prescribed using formulas like the Parkland formula to restore intravascular volume and prevent shock.
• Monitor urine output: Use urine output as an indicator of adequate perfusion. The goal for adults is at least 0.5 mL/kg/hr (approximately 30-50 mL/hr).
• Monitor vital signs: Track trends in blood pressure, heart rate, and respiratory rate to detect worsening hypovolemia or shock.
• Assess peripheral circulation: In burns involving extremities, check for signs of impaired circulation (e.g., delayed capillary refill or weak pulses) and prepare for interventions like escharotomy if needed.
• Prevent infection: Maintain a sterile environment during wound care, as fluid shifts can weaken immune defenses and increase infection risk.

✘Incorrect answer options:

Intense pain. While intense pain from burns can cause tachycardia due to sympathetic nervous system activation, it does not typically result in hypotension. Hypotension in this case is more likely due to fluid loss rather than pain.

Hemorrhage. Hemorrhage (significant blood loss) can cause hypotension and tachycardia, but it is not a typical finding in burn injuries unless there is associated trauma or severe vascular damage. The question does not describe active bleeding, making this an unlikely cause.

Carbon monoxide poisoning. Carbon monoxide poisoning is a potential complication of burns in enclosed spaces (e.g., house fires). While it can cause tachycardia and altered mental status, hypotension is not a typical finding. Key signs of carbon monoxide poisoning include headache, confusion, and cherry-red skin coloration, none of which are mentioned in this scenario.