MSN Exam for Burn Management and Care 1

EXPLANATION

✔Correct answer:

The patient's oxygen saturation (SpO2) is 97%. Oxygen saturation (SpO2) is a direct and objective indicator of the adequacy of gas exchange in the lungs. It reflects the percentage of hemoglobin molecules in the blood that are bound with oxygen. A reading of 97% indicates that the patient’s ventilation (air movement in and out of the lungs) and oxygenation (the process of oxygen diffusing from the lungs into the bloodstream) are effective, assuming no carbon monoxide poisoning or other hemoglobin-binding interference.

Normal SpO2 values are typically 95%-100% in healthy individuals. Values in this range demonstrate that the lungs are effectively oxygenating the blood, and by extension, that ventilation and gas exchange are adequate.

Think of oxygen saturation like the fuel gauge in a car. A reading of 97% is like having a full tank, indicating that the system is working efficiently and oxygen is being delivered to the "engine" (body tissues).

If a patient's SpO2 is within normal range, confirm that their respiratory function is stable. For patients with compromised respiratory function, take further action based on their clinical presentation.

• Monitor SpO2 regularly: Use pulse oximetry to continuously assess oxygen levels, especially in patients at risk for hypoxemia.
• Assess for changes: Watch for signs of respiratory distress, such as increased work of breathing, use of accessory muscles, or cyanosis.
• Supplemental oxygen: Administer oxygen therapy as prescribed if SpO2 falls below acceptable levels (e.g., < 90%).
• Evaluate underlying causes: Investigate factors that could affect oxygenation, such as lung diseases (e.g., COPD, asthma), infection, or trauma.
• Correlate with arterial blood gases (ABGs): In some cases, ABG analysis may be needed for a more comprehensive evaluation of gas exchange.

✘Incorrect answer options:

The patient is able to converse comfortably. While being able to converse indicates that the patient’s airway is patent and that ventilation is occurring, it does not provide direct evidence of effective gas exchange or oxygenation. For example, someone could have adequate ventilation but poor oxygenation due to underlying pulmonary issues (e.g., impaired alveolar gas exchange).

The patient is alert and oriented. Being alert and oriented suggests adequate perfusion and oxygen delivery to the brain, but it is not the most definitive measure of respiratory function. A patient could be alert while compensating for hypoxemia through increased work of breathing or tachypnea.

The patient exhibits unrestricted chest wall movement during respiration. Unrestricted chest wall movement indicates that the mechanics of breathing are intact, but this does not confirm effective gas exchange or oxygenation. For example, a patient with conditions like pulmonary embolism or pulmonary edema may have normal chest wall movement but still have impaired gas exchange.

EXPLANATION

✔Correct answer:

"This mask should help reduce the severity of my facial scars." Wearing a facial mask pressure garment is an essential therapy for burn patients to manage scar formation. These garments apply consistent pressure to healing skin, which helps reduce hypertrophic scar development and minimize keloid formation. Pressure therapy promotes a more even distribution of collagen fibers during the wound-healing process, leading to less severe scarring. This statement demonstrates the patient’s understanding of the purpose of the pressure garment, which is to improve the appearance and flexibility of scars rather than completely eliminate them.

How does pressure therapy work? After a burn injury, the body produces excess collagen during the healing process, which can lead to raised, thick scars. Pressure garments compress the scar tissue, reducing blood flow to the area and decreasing collagen production. This results in flatter, softer, and less visible scars over time.

Imagine pressing on dough while it rises to control its shape. Without pressure, the dough expands unevenly, just like scar tissue. Consistent pressure helps guide the dough (scar tissue) into a smoother, more even form.

Educating the patient about the proper use and care of pressure garments is critical to ensure compliance and maximize therapeutic outcomes.

• Teach the patient to wear the mask for 23 hours a day, removing it only for hygiene or skin care purposes.
• Explain that pressure garments must be custom-fitted to ensure they are effective and comfortable.
• Instruct the patient to watch for signs of skin irritation, breakdown, or poor circulation under the garment.
• Encourage regular follow-up appointments to assess scar progression and adjust the fit of the garment as needed.
• Discuss the long-term commitment required, as pressure therapy often continues for 12-18 months depending on the severity of the burns and scarring.

✘Incorrect answer options:

"This mask will help make sure my ears don’t stick out." While pressure garments can be used to help contour areas of the body, their primary purpose is to reduce scar formation, not to reposition or reshape features like the ears.

"It will shield my skin from damage caused by sunlight." Pressure garments are not specifically designed for sun protection. Burned skin is indeed sensitive to sunlight, but sun protection should be achieved using sunscreen, hats, or physical barriers, not pressure garments.

"Wearing the mask will stop my scars from becoming permanent." Pressure garments do not completely prevent scarring or make scars disappear. Instead, they reduce the severity and prominence of scars. Some level of scarring may remain despite therapy.

EXPLANATION

✔Correct answer:

It may cause the autografts to become dislodged. Autografts, which involve transferring skin from a donor site on the patient to a burn site, require time to adhere and establish a new blood supply. Performing arm exercises too soon after grafting can disrupt this delicate process and cause the autografts to become dislodged, leading to graft failure. Movement may create tension or shear forces on the grafted skin, preventing proper adherence to the wound bed. This can result in poor healing, increased risk of infection, and the need for repeat grafting.

During the first 5-7 days after an autograft, the priority is to protect the graft site from movement, pressure, and friction to ensure it integrates with the wound bed. Immobilization of the affected area is essential during this period to allow the graft to "take" effectively.

Imagine taping a delicate sheet of paper onto a surface with glue. If you move or stretch the paper before the glue sets, it will lift off and not stick properly. Similarly, the skin graft needs time to attach firmly to the wound bed before being moved.

Nurse Kim should educate the patient on the importance of immobilization and provide clear instructions on activity restrictions to prevent graft complications.

• Advise the patient to avoid moving or exercising the grafted area for at least 5-7 days post-surgery or as directed by the healthcare provider.
• Elevate the arms to reduce swelling and support proper circulation to the grafted area.
• Inspect the graft site daily for signs of dislodgement, infection (e.g., redness, warmth, drainage), or necrosis.
• Collaborate with physical and occupational therapists to initiate a gradual range-of-motion program after the graft has stabilized.
• Reassure the patient that arm exercises will be reintroduced later in the recovery process to maintain flexibility and prevent contractures.

✘Incorrect answer options:

It could worsen swelling in the arms. While swelling is a concern after burns, exercise alone is unlikely to worsen it significantly. Elevation and controlled movement are actually beneficial for reducing edema, but only after the grafts are stabilized.

It might lead to more severe scarring. Scar formation is primarily influenced by the depth of the burn and the healing process. Early movement of the grafted arms does not directly affect scar severity but rather risks dislodging the graft, which could lead to poor healing and secondary complications.

It could reduce blood flow to the fingers. Exercising the arms does not directly reduce blood flow to the fingers. In fact, physical activity generally promotes circulation. The primary concern in this situation is the potential disruption of the grafts, not distal circulation.

EXPLANATION

✔Correct answer:

Full-thickness burn. The description of the burn—white appearance, leathery texture, absence of blisters, lack of bleeding, and minimal pain—indicates a full-thickness burn. Full-thickness burns involve the destruction of all layers of the skin, including the epidermis, dermis, and potentially subcutaneous tissues. These burns damage nerve endings, which is why patients often report minimal or no pain despite the severity of the injury.

Key features of full-thickness burns:  

• Appearance: White, waxy, leathery, or charred (eschar may be present).
• Texture: Firm, dry, and inelastic (due to coagulated proteins).
• Pain: Minimal or absent due to the destruction of nerve endings.
• Healing: Does not heal spontaneously and typically requires surgical intervention, such as excision and skin grafting.

Think of the skin like a multi-layered cake. A full-thickness burn is like cutting through all the layers of the cake down to the plate—it’s completely destroyed, and the nerves (like frosting layers) are no longer functional, so there’s little pain sensation.

Full-thickness burns are severe and require specialized care to prevent complications such as infection, hypovolemia, and delayed healing.

• Initial stabilization: Focus on airway, breathing, and circulation (the ABCs). Provide fluid resuscitation based on the Parkland formula.
• Wound care: Maintain sterility to reduce infection risk. Escharotomy may be needed to relieve pressure caused by the leathery, inelastic skin.
• Surgical management: Prepare the patient for potential skin grafting procedures to promote healing.
• Pain management: Although pain is minimal in the burned area, adjacent tissues (e.g., partial-thickness burns) may be painful. Provide appropriate analgesics.
• Psychosocial support: Full-thickness burns often result in disfigurement and functional limitations. Provide emotional support and involve multidisciplinary teams, such as physical therapy and psychological counseling.

✘Incorrect answer options:

Superficial partial-thickness burn: This type of burn involves the epidermis and part of the dermis. It is characterized by redness, moistness, blistering, and significant pain. The described burn lacks these features, ruling out superficial partial-thickness burns.

Deep partial-thickness burn: This burn involves deeper layers of the dermis and is characterized by red or white appearance, delayed capillary refill, and blisters. Although deep partial-thickness burns may appear white, they are often moist and have some sensation. The leathery texture and lack of pain described in this case point to a full-thickness burn.

Superficial burn: Superficial burns (first-degree burns) only involve the epidermis and present as red, dry, and painful burns without blistering (e.g., sunburn). The described burn is far more severe, involving deeper layers of the skin.

EXPLANATION

✔Correct answer:

Avoid applying water to the affected area. White phosphorus chemical burns require specific management because water can exacerbate the injury. White phosphorus is a highly reactive chemical that ignites when exposed to oxygen, producing heat and toxic fumes. If water is applied, it may temporarily stop the burning, but as soon as the water evaporates, the white phosphorus reignites, causing further damage to the tissue. Therefore, applying water to a white phosphorus burn is contraindicated. Instead, the primary nursing intervention is to carefully remove visible white phosphorus particles using forceps or a wet dressing, while keeping the burn site covered to limit oxygen exposure.

Key steps in managing white phosphorus burns:

1. Immediately protect yourself with appropriate personal protective equipment (PPE) to avoid exposure.
2. Avoid irrigating the burn with water.
3. Remove any visible particles of white phosphorus using forceps or saline-soaked gauze to keep the area moist and prevent ignition.
4. Cover the burn area with wet dressings soaked in saline to keep the particles inactive and reduce exposure to oxygen.
5. Monitor for signs of systemic toxicity (e.g., hypocalcemia, cardiac arrhythmias) due to phosphorus absorption.

Think of white phosphorus like a small sparkler firework that reignites when exposed to air. Applying water might cool it temporarily, but it will start burning again once the water dries. Instead, you need to remove the sparkler (phosphorus particles) safely and keep it damp and isolated from air.

Immediate management is critical to prevent further injury and systemic complications from white phosphorus burns.

• Use forceps or saline-soaked gauze to carefully remove any visible phosphorus particles.
• Keep the wound covered with a saline-soaked dressing to prevent oxygen exposure and re-ignition.
• Avoid applying water directly to the burn, as it can worsen the injury.
• Monitor the patient for systemic toxicity, such as hypocalcemia, which may occur due to phosphorus absorption into the bloodstream.
• Provide supportive care, including pain management and tetanus prophylaxis.
• Collaborate with the burn care team for further debridement and management in a controlled environment.

✘Incorrect answer options:

Immediately rinse the skin thoroughly with running water from a shower, hose, or faucet. This is appropriate for many chemical burns (e.g., acids or alkalis), but not for white phosphorus burns. Rinsing with water can temporarily extinguish the burning but leads to re-ignition as soon as the water evaporates.

Alternate between applying water and ice to the burn site. Ice is contraindicated in burn management because it can worsen tissue damage by causing vasoconstriction and hypothermia. For white phosphorus burns specifically, ice does not stop the chemical reaction and is not a recommended treatment.

Wash the chemical off using warm water, then follow with a flush of cool water. Applying warm or cool water is also contraindicated for white phosphorus burns due to the risk of re-ignition and further damage. The priority is to remove particles and limit oxygen exposure.

EXPLANATION

✔Correct answer:

A third-degree burn. The description of the burn as white, leathery, and without blisters is consistent with a third-degree burn (also called a full-thickness burn). Third-degree burns involve the complete destruction of both the epidermis and dermis, often extending into the subcutaneous tissue. These burns are characterized by a white or charred appearance, a leathery texture, and the absence of pain in the affected area due to the destruction of nerve endings. Unlike superficial burns, third-degree burns do not form blisters because the dermis, where blister formation occurs, is completely damaged.

Key Features of a Third-Degree Burn:

• Appearance: White, brown, or black eschar; dry and leathery.
• Sensation: Typically painless in the center due to nerve damage but may have painful areas at the edges where partial-thickness injury may coexist.
• Healing: Requires medical intervention, as these burns cannot regenerate new skin and typically need grafting.

Think of the skin layers like the layers of a cake. A first-degree burn affects just the frosting, a second-degree burn digs into the sponge layer, but a third-degree burn destroys the cake entirely, leaving only the solid, charred bottom layer.

Burns of this severity require prompt medical attention, as they can lead to complications such as infection, fluid loss, and poor wound healing.

• Assess the size and depth of the burn using tools such as the Rule of Nines to estimate the percentage of total body surface area (TBSA) affected.
• Monitor for signs of systemic complications, such as hypovolemia and infection.
• Prepare for interventions such as wound debridement, escharotomy (if circulation is compromised), or skin grafting.
• Provide pain management, emotional support, and patient education regarding long-term rehabilitation.
• Collaborate with a multidisciplinary burn care team, including surgeons, physical therapists, and nutritionists.

✘Incorrect answer options:

A first-degree burn. First-degree burns (superficial burns) affect only the epidermis. They are characterized by redness, pain, and the absence of blisters or significant damage to deeper skin layers. The described burn, which is white and leathery, is too severe to be classified as first-degree.

A second-degree burn. Second-degree burns (partial-thickness burns) involve the epidermis and part of the dermis. These burns are typically red, blistered, and very painful. The absence of blisters and the leathery texture in the description rule out second-degree burns.

A fourth-degree burn. Fourth-degree burns extend beyond the skin layers into underlying tissues such as muscles, tendons, or bones. These burns typically appear charred or black and are much deeper than the description provided, which focuses on skin damage.

EXPLANATION

✔Correct answer:

Ensuring the patient is hydrated and starting IV fluids if necessary. The primary focus when managing a patient with extensive solar burns is maintaining hydration and addressing the risk of fluid loss. Burns, including those caused by the sun, can lead to fluid loss through damaged skin and increased evaporation. In cases involving significant body surface area (chest, back, face, and arms), fluid loss can result in dehydration and potential hypovolemia. Nurse Carla's priority should be to assess the patient’s hydration status and initiate IV fluids if necessary to prevent complications such as electrolyte imbalances, decreased perfusion, or organ dysfunction.

The skin acts as a barrier to fluid loss, and burns compromise this function. Fluid shifts from the vascular compartment to the interstitial spaces due to increased capillary permeability, leading to hypovolemia. Ensuring adequate hydration through oral fluids or IV therapy is vital to support hemodynamic stability and cellular function.

Think of the body as a water tank that needs a constant supply to function. When the skin barrier is damaged, it’s like the tank has a leak, causing it to lose water faster. Replenishing fluids is like refilling the tank to ensure the system works properly.

Fluid management is the foundation of initial care for burns, particularly when large areas of the body are affected. Nurse Carla should assess and address fluid loss promptly to prevent complications.

• Assess the patient’s hydration status by monitoring vital signs, skin turgor, mucous membranes, and urine output.
• Provide oral rehydration if the patient is stable and able to tolerate fluids.
• Start IV fluids if signs of dehydration or hypovolemia are present (e.g., tachycardia, hypotension, decreased urine output).
• Monitor for signs of electrolyte imbalances, such as muscle cramps, confusion, or irregular heart rate.
• Educate the patient about the importance of hydration and avoiding prolonged sun exposure during recovery.

✘Incorrect answer options:

Applying topical antibiotic ointments to prevent infection. While infection prevention is essential for deeper burns, solar burns are typically superficial or partial-thickness and less prone to infection. Applying aloe vera or a non-antibiotic soothing cream is more appropriate for solar burns unless there are open blisters or signs of infection.

Administering oral pain medication to relieve discomfort. Pain management is important but not the primary focus in this situation. Addressing hydration and preventing fluid loss takes precedence, as untreated dehydration can lead to systemic complications, including shock. Pain relief can be addressed simultaneously or after stabilizing hydration status.

Educating the patient on the importance of using sunscreen in the future. While prevention education is important, it is not the immediate priority in the acute phase of burn management. This can be addressed after ensuring the patient’s physical needs, such as hydration and comfort, have been met.

EXPLANATION

✔Correct answer:

"The risk significantly decreases once the burn wounds are closed." Infection is a major concern in patients with severe burns because the skin, which serves as the body's primary barrier against pathogens, is damaged. The heightened risk of infection persists until the burn wounds are completely closed, either through natural healing, surgical intervention (e.g., skin grafts), or the application of artificial skin.

Open wounds provide an entry point for microorganisms, increasing the likelihood of localized infections, sepsis, or systemic infections. Once the wounds are closed, either by epithelialization or grafting, the barrier function of the skin is restored, significantly reducing the risk of infection.

Think of the skin like a locked door that keeps intruders (bacteria) out of the house (the body). When the door is broken (burned skin), it’s easy for intruders to get inside. Repairing or replacing the door (closing the wound) restores the barrier and keeps the intruders out.

To reduce the risk of infection and support wound healing in burn patients, nurses must employ strict infection prevention measures and provide education to families.

• Wound care: Perform meticulous wound care using sterile techniques to prevent contamination.
• Monitor for signs of infection: Assess for redness, swelling, increased pain, fever, purulent drainage, or foul odor from the wound site.
• Antimicrobial therapy: Administer prescribed antibiotics or topical antimicrobial agents to reduce the bacterial load in the wound bed.
• Encourage nutrition: Promote a high-protein, high-calorie diet to support immune function and wound healing.
• Educate the family: Teach the family about proper hand hygiene and how to recognize signs of infection to ensure ongoing care after discharge.

✘Incorrect answer options:

"The risk decreases once fluid shifts back into the bloodstream." Fluid shifts, particularly during the acute phase of burn injury, impact hemodynamic stability rather than directly influencing infection risk. While stabilizing fluid and electrolyte balance is critical for patient survival, the risk of infection remains high as long as the wounds are open.

"The risk decreases once intravenous fluids are stopped." The cessation of intravenous fluids indicates improved fluid balance but does not directly correlate with a reduction in infection risk. Open wounds remain the primary source of infection risk.

"The risk decreases once the patient's weight returns to normal." Weight normalization indicates progress in nutritional status and recovery but does not directly address infection risk. Wounds must be closed for the infection risk to decrease, regardless of the patient's weight.

EXPLANATION

✔Correct answer:

Bright cherry red appearance of the mucous membranes. The bright cherry red appearance of the mucous membranes is a classic clinical finding of carbon monoxide (CO) poisoning. Carbon monoxide binds to hemoglobin with an affinity 200-250 times greater than oxygen, forming carboxyhemoglobin. This impairs oxygen delivery to tissues and causes tissue hypoxia, despite oxygen saturation readings that may appear normal. The bright red color is due to the increased levels of carboxyhemoglobin in the blood, which gives the blood a cherry red appearance. This sign, though rare, is a critical indicator of CO poisoning in burn patients or those exposed to smoke inhalation during a fire.

Carbon monoxide competes with oxygen for binding sites on hemoglobin, reducing the blood's oxygen-carrying capacity. This results in tissue hypoxia, which can cause neurological symptoms (e.g., headache, confusion), cardiovascular effects (e.g., tachycardia, hypotension), and in severe cases, death.

Think of hemoglobin like a bus that carries oxygen to tissues. Carbon monoxide is like a VIP passenger that kicks oxygen off the bus and takes up all the seats, preventing oxygen delivery to where it’s needed.

Prompt recognition and treatment of carbon monoxide poisoning are essential to prevent severe hypoxia and organ damage.

• Administer 100% oxygen via a non-rebreather mask to quickly displace carbon monoxide from hemoglobin.
• Prepare for hyperbaric oxygen therapy if available and indicated, as it enhances the elimination of carbon monoxide.
• Monitor the patient’s carboxyhemoglobin levels using blood gas analysis or a co-oximeter (pulse oximetry cannot differentiate carboxyhemoglobin from oxyhemoglobin).
• Assess for neurological symptoms such as confusion, headache, or loss of consciousness, which suggest hypoxia or more severe CO poisoning.
• Educate the patient and family about carbon monoxide sources and prevention strategies, including the use of CO detectors in the home.

✘Incorrect answer options:

A pulse oximetry reading of 80%. Pulse oximetry is unreliable in detecting carbon monoxide poisoning because it cannot differentiate between oxyhemoglobin and carboxyhemoglobin. A patient with CO poisoning may have normal or falsely high pulse oximetry readings, despite severe hypoxia.

Expiratory stridor and nasal flaring. These findings suggest upper airway obstruction or respiratory distress, which could occur in smoke inhalation injuries, but they are not specific to carbon monoxide poisoning. CO poisoning primarily causes systemic hypoxia rather than localized airway symptoms.

Carbon particles observed in the patient's sputum. The presence of carbon particles in sputum is indicative of smoke inhalation injury, which increases the risk of airway burns and pulmonary complications. While this finding warrants attention, it does not confirm carbon monoxide poisoning.

EXPLANATION

✔Correct answer:

Urine output of 20 mL/hour. A urine output of 20 mL/hour is below the normal range (at least 30-50 mL/hour) and indicates inadequate kidney perfusion, potentially caused by hypovolemia or burn shock, which are common complications of severe burns. Burns covering large areas, especially second- and third-degree burns, result in significant fluid loss due to capillary leakage and evaporative losses. Inadequate fluid resuscitation leads to decreased renal perfusion and impaired kidney function, which is why urine output is a key marker for assessing fluid status. Prompt attention is required to prevent acute kidney injury (AKI) and other complications.

Burns disrupt capillary membranes, causing plasma and proteins to leak into interstitial spaces (third-spacing). This leads to reduced intravascular volume and decreased cardiac output, compromising organ perfusion, including the kidneys.

Imagine the body as a car engine that needs oil to function. If there’s a leak (fluid loss from burns), the engine doesn’t get enough oil (kidney perfusion), leading to damage (kidney injury). Monitoring the oil level (urine output) ensures the system is working properly.

Nurse Julia should address the low urine output immediately by reassessing the patient’s fluid status and collaborating with the healthcare team to adjust the fluid resuscitation plan.

• Monitor urine output hourly using an indwelling catheter, and ensure it is maintained at 30-50 mL/hour in adults.
• Assess for other signs of hypovolemia, such as hypotension, tachycardia, and poor capillary refill.
• Adjust IV fluid administration as needed based on urine output and vital signs, following guidelines such as the Parkland formula during the resuscitation phase.
• Monitor kidney function by checking blood urea nitrogen (BUN), creatinine, and electrolyte levels.
• Educate the patient about the importance of fluid balance and hydration during the recovery process.

✘Incorrect answer options:

PaO2 level of 80 mm Hg. A PaO2 of 80 mm Hg is within the normal range (80-100 mm Hg), indicating adequate oxygenation. While airway management is critical for patients with facial burns, this value does not suggest a complication requiring immediate intervention.

Pulmonary secretions that are white in color. White-colored pulmonary secretions are not typically alarming and are often considered normal. However, if the secretions were thick, discolored (e.g., yellow or green), or accompanied by respiratory distress, they might indicate an infection or inhalation injury requiring further evaluation.

A rectal temperature of 100.6°F (38°C). A mild fever is common in burn patients due to the systemic inflammatory response associated with burns. While persistent or higher fevers (>38.5°C/101.3°F) may indicate infection, a temperature of 100.6°F is not concerning on its own.

EXPLANATION

✔Correct answer:

Notify the physician and prepare to obtain blood cultures. The presentation of low temperature, hypotension, and diarrhea in a burn patient two weeks after injury is highly suspicious for sepsis or septic shock, which is a medical emergency. Burn patients are at a significant risk for infections due to the loss of the skin barrier, compromised immunity, and invasive interventions. The nurse's first priority is to notify the physician to ensure prompt diagnosis and treatment, which begins with obtaining blood cultures to identify the source of infection and guide antibiotic therapy. Early recognition and intervention are critical in preventing progression to multisystem organ failure.

Why blood cultures? Sepsis often involves bacteremia (presence of bacteria in the bloodstream). Blood cultures are essential to identify the causative organism and determine its antibiotic sensitivity, enabling appropriate treatment. While awaiting results, broad-spectrum antibiotics may be initiated to address the suspected infection.

In septic shock, systemic inflammation and bacterial toxins lead to widespread vasodilation, capillary leakage, and impaired organ perfusion. Symptoms such as hypotension, hypothermia (a late sign in sepsis), and diarrhea suggest systemic involvement. Left untreated, septic shock can quickly progress to multi-organ dysfunction and death.

Think of the bloodstream as a clean river. If harmful bacteria (pollutants) enter the river, they spread quickly, harming the ecosystem (body). Blood cultures help identify the specific pollutants, so the right solution (antibiotic) can be used to clean the water effectively.

Early detection and treatment are essential to prevent mortality in septic patients. Nurse Sarah should focus on preparing for immediate diagnostic and therapeutic interventions.

• Notify the physician immediately about the patient’s symptoms (low temperature, hypotension, diarrhea).
• Prepare to collect blood cultures and other relevant specimens (e.g., wound swab, urine sample) before administering antibiotics.
• Monitor vital signs closely, especially blood pressure, heart rate, temperature, and oxygen saturation.
• Anticipate orders for broad-spectrum antibiotics, IV fluids for hemodynamic support, and oxygen if necessary.
• Reassess the patient frequently for signs of worsening septic shock (e.g., decreased urine output, altered mental status).

✘Incorrect answer options:

Administer antidiarrheal medication as prescribed. Diarrhea in the context of a burn patient with systemic symptoms (low temperature and hypotension) is more likely a symptom of sepsis rather than a standalone gastrointestinal issue. Administering antidiarrheal medication may mask symptoms and delay the recognition and treatment of the underlying life-threatening condition.

Increase the patient’s oral fluid intake to prevent dehydration. While preventing dehydration is important in burn care, oral fluid intake is insufficient to address the hypotension and hypoperfusion caused by septic shock. The focus should be on identifying the source of infection and initiating treatment, which includes IV fluid resuscitation, not just oral hydration.

Check the patient's pain levels and adjust analgesics accordingly. Pain management is important in burn care but is not the priority in this situation. Addressing the systemic symptoms of sepsis (e.g., infection and hypoperfusion) is more urgent to prevent deterioration. Analgesic adjustments can be addressed later after stabilizing the patient.

EXPLANATION

✔Correct answer:

"I will limit movement of my arm." During the initial postoperative phase following the application of artificial skin (a bioengineered skin substitute or graft), minimizing movement of the affected area is critical to allow proper adherence of the graft to the wound bed. Excessive movement can disrupt the graft, leading to poor integration, failure of the graft, and delayed healing.

Artificial skin requires a stable environment to promote vascularization, where blood vessels grow into the graft and provide the necessary nutrients for healing. Therefore, limiting movement of the arm during the first 7 days is a key part of postoperative care to ensure optimal healing.

Think of the graft like a freshly planted tree. Just as you avoid disturbing the soil around a young tree to let its roots grow and anchor into the ground, you avoid moving the grafted area to let it "take root" and attach properly to the underlying tissue.

Educating patients like Mr. Davis on proper postoperative care is essential to ensure graft success and prevent complications.

• Immobilization: Emphasize the importance of limiting movement of the grafted area to prevent disruption of the graft.
• Wound Care Instructions: Teach Mr. Davis how to properly clean and dress the grafted area as directed by the healthcare provider.
• Monitor for Signs of Infection: Instruct the patient to report any signs of infection, such as redness, swelling, increased pain, or discharge from the grafted area.
• Nutrition and Hydration: Encourage a high-protein diet to support tissue healing and adequate fluid intake to maintain hydration.
• Follow-Up Care: Reinforce the importance of attending follow-up appointments for assessment of graft adherence and healing progress.

✘Incorrect answer options:

"I will decrease the amount of protein I eat." Protein is essential for wound healing, as it supports tissue regeneration and repair. Decreasing protein intake would hinder the healing process and increase the risk of complications such as delayed graft adherence or wound breakdown.

"I will avoid going outside." While avoiding excessive sun exposure to the graft site is important, there is no need to completely avoid going outside unless otherwise directed by the healthcare provider. Protecting the graft from infection and trauma is more critical than avoiding outdoor activities.

"I will drink fewer fluids." Proper hydration is essential for healing, as it supports blood circulation and tissue repair. Reducing fluid intake would be counterproductive, especially in burn patients who are at increased risk of dehydration due to fluid loss from the wound.

EXPLANATION

✔Correct answer:

As soon as the fluid shift has stabilized. Early mobilization is a cornerstone of burn care, aimed at preventing complications such as contractures, muscle atrophy, and decreased cardiopulmonary function. However, initiating ambulation too early, before the fluid shift has stabilized, can be detrimental. During the acute phase of burn injury, significant fluid shifts occur due to increased capillary permeability, leading to edema and hypovolemia. Ambulation during this unstable period can further compromise hemodynamic stability, potentially leading to shock or other complications. Once the fluid shift has stabilized, evidenced by improved hemodynamic parameters (e.g., stable blood pressure, adequate urine output), it is safe and beneficial to begin mobilizing the patient.

The fluid shift in burn patients involves a massive movement of fluid from the intravascular space to the interstitial space due to increased capillary permeability. This results in edema, decreased circulating blood volume (hypovolemia), and potential electrolyte imbalances. Initiating ambulation before the fluid shift stabilizes can exacerbate hypovolemia and compromise organ perfusion.

Imagine a water balloon (the patient's body) with a small leak (the burn injury). If you try to move the balloon vigorously before plugging the leak (stabilizing the fluid shift), more water will spill out, causing the balloon to deflate further. Once the leak is plugged, you can move the balloon without losing more water. Similarly, ambulating a burn patient before fluid stabilization can lead to further hemodynamic instability.

Early mobilization in burn patients requires careful planning and coordination with the interdisciplinary team.

• Monitor hemodynamic parameters closely, including blood pressure, heart rate, urine output, and central venous pressure (CVP), to determine fluid status.
• Collaborate with physical and occupational therapists to develop a safe and effective mobilization plan.
• Begin with passive range-of-motion exercises and progress to active exercises and ambulation as tolerated.
• Assess the patient's pain level and administer analgesics as needed to facilitate participation in mobilization activities.
• Monitor for signs of complications during and after mobilization, such as dizziness, lightheadedness, or increased edema.

✘Incorrect answer options:

After all full-thickness burns have been covered with skin grafts. Waiting until all full-thickness burns are covered with skin grafts would significantly delay mobilization, leading to increased risk of complications. Early mobilization should begin well before this stage, as soon as the patient is hemodynamically stable.

Once the patient’s temperature has been stable for 24 hours. While a stable temperature is a positive indicator of overall improvement, it is not the primary factor determining when to begin ambulation. Fluid stabilization is the more critical factor to consider.

Immediately following the completion of wound debridement. While wound debridement is an important part of burn care, it does not dictate the timing of ambulation. Ambulation should be initiated based on hemodynamic stability, not solely on wound care procedures.

EXPLANATION

✔Correct answer:

Deficiency in Vitamin D. Patients recovering from full-thickness burns are at a significant risk for developing Vitamin D deficiency as a long-term consequence. This is because full-thickness burns destroy the skin's epidermis, which contains keratinocytes responsible for synthesizing Vitamin D when exposed to ultraviolet (UV) light. With the loss of skin integrity and reduced sun exposure during the recovery phase (due to wound care and protective measures to prevent further damage), the body’s ability to produce Vitamin D is severely impaired.

Vitamin D is essential for calcium absorption, bone health, and immune function. Deficiency can lead to conditions such as osteoporosis, delayed wound healing, and an increased risk of infections, all of which are particularly concerning in burn patients undergoing prolonged recovery and rehabilitation.

In healthy skin, UVB radiation from sunlight converts 7-dehydrocholesterol to previtamin D3, which is then converted to active Vitamin D (calcitriol) through processes in the liver and kidneys. Full-thickness burns damage the dermis and epidermis, limiting this natural process and increasing the likelihood of deficiency.

Think of the skin as a solar panel that generates energy (Vitamin D) when exposed to sunlight. If the panel is damaged (as with a full-thickness burn), it can no longer produce energy efficiently, leading to a deficiency.

Long-term care for burn patients should include strategies to address and monitor for Vitamin D deficiency, as well as other potential nutritional deficiencies.

• Educate the patient on the importance of Vitamin D in recovery and overall health.
• Encourage dietary intake of Vitamin D-rich foods, such as fortified milk, fatty fish, and eggs.
• Consider Vitamin D supplementation if the patient is unable to get adequate sun exposure or has confirmed deficiency through lab tests.
• Monitor calcium and Vitamin D levels periodically, especially in patients with large burn areas.
• Collaborate with a dietitian to develop a nutrition plan tailored to the patient’s needs.

✘Incorrect answer options:

Deficiency in Vitamin A. Vitamin A plays a key role in epithelialization and immune function, and while it may be beneficial during wound healing, it is not commonly deficient due to full-thickness burns alone. Supplementation may be helpful in acute recovery but is not as critical as Vitamin D for long-term consequences.

Deficiency in Vitamin B. Vitamin B (specifically B1, B6, or B12) deficiencies are not directly linked to burn injuries unless the patient has underlying nutritional deficiencies or poor dietary intake. While B vitamins are important for energy metabolism and tissue repair, their deficiency is not a typical long-term issue in burn recovery.

Deficiency in Vitamin C. Vitamin C is essential for collagen synthesis and wound healing, but its deficiency is usually an issue in the acute phase if dietary intake is poor. Long-term Vitamin C deficiency is uncommon unless the patient has a persistently poor diet or additional risk factors like smoking.

EXPLANATION

✔Correct answer:

Impaired Adjustment. In the rehabilitative phase of burn recovery, the primary focus shifts from acute physical stabilization to long-term functional and psychosocial recovery. Burn injuries can result in significant life changes, including physical disabilities, body image disturbances, loss of independence, and social isolation. "Impaired Adjustment" reflects the challenges patients face as they adapt to these changes and integrate back into daily life, making it a priority nursing diagnosis in this phase.

The rehabilitative phase also emphasizes psychosocial well-being, coping strategies, and emotional health. This involves supporting the patient in accepting changes, regaining confidence, and building resilience for a better quality of life.

Imagine someone learning to live with a new pair of glasses after losing their natural vision. They not only need to adjust physically but also emotionally to the changes. Similarly, a burn patient must adjust to their "new normal" physically, emotionally, and socially.

To address "Impaired Adjustment," Nurse Rodriguez should implement interventions focused on emotional support, education, and empowerment.

• Facilitate psychosocial support: Encourage the client to express feelings about their injury and recovery process. Refer them to support groups or counseling as needed.
• Promote positive body image: Educate the client on scar management techniques, such as compression garments and topical treatments, to enhance confidence.
• Set realistic goals: Help the client set achievable rehabilitation goals for physical recovery and social reintegration.
• Provide education: Offer guidance on lifestyle adjustments, managing chronic pain, and performing activities of daily living (ADLs) with any physical limitations.
• Collaborate with interdisciplinary teams: Work with physical therapists, occupational therapists, and mental health professionals to maximize recovery.

✘Incorrect answer options:

Acute Pain. While managing pain is essential during the acute and rehabilitative phases, pain is typically less severe during the rehabilitative phase compared to the acute phase. The focus in this phase is more on long-term recovery and adaptation rather than acute physical needs.

Deficient Diversional Activity. While boredom and lack of engagement may occur during long-term recovery, it is not a priority nursing diagnosis compared to the emotional and psychosocial impact of adjusting to a burn injury.

Imbalanced Nutrition: Less than Body Requirements. Nutritional needs are a significant focus during the acute and early recovery phases due to the high metabolic demands of wound healing. However, in the rehabilitative phase, the priority shifts to psychosocial and functional recovery. Nutritional concerns may still exist but are not the top priority.

EXPLANATION

✔Correct answer:

31.5% The Rule of Nines is a widely used method for estimating the percentage of total body surface area (TBSA) affected by burns. This method divides the body into regions, each corresponding to a specific percentage of TBSA.

Here’s the breakdown for the areas affected in this patient:

• Face and Neck: This region accounts for 4.5% of TBSA.
• Anterior Chest (Upper Anterior Trunk): This area accounts for 9% of TBSA.
• Both Arms (including hands): Each arm is assigned 9%, which totals 18% for both arms.

Adding these values together gives 4.5% (Face and Neck) + 9% (Anterior Chest) + 18% (Both Arms) = 31.5% TBSA burned. Therefore, 31.5% is the most accurate calculation for this patient’s TBSA burned.

Think of the body as a grid with specific percentages assigned to each section, like pieces of a puzzle. Using the Rule of Nines is similar to adding up these puzzle pieces to determine the total percentage affected by burns.

Nurses managing a patient with burns covering 31.5% of their TBSA must focus on fluid resuscitation, airway management (especially for face/neck burns), and preventing infection.

• Monitor for airway compromise, particularly due to facial and neck burns that can lead to edema and obstruction.
• Initiate fluid resuscitation using formulas such as the Parkland formula to prevent hypovolemic shock.
• Assess for signs of infection and maintain a sterile environment during wound care.
• Provide adequate pain management and emotional support, as burns can cause severe discomfort and psychological distress.
• Collaborate with a multidisciplinary team, including a burn specialist, to ensure optimal care.

✘Incorrect answer options:

25.5% This calculation omits the contribution of one or more burned areas. For example, it might exclude part of the arms or the anterior chest in error, leading to an underestimate of the TBSA.

35% While close, this calculation slightly overestimates the TBSA. Using the Rule of Nines strictly, the sum of the specified areas totals 31.5%.

40% This figure significantly overestimates the TBSA and likely includes areas not affected by burns, such as the posterior trunk or legs, which are not part of this patient’s description.

EXPLANATION

✔Correct answer:

Use of knee splints to maintain proper positioning. Preventing contractures is a critical aspect of burn recovery care, especially in areas like the legs where joint immobility is a significant risk. Contractures occur when scar tissue tightens and restricts the range of motion in joints, often leading to deformities and functional limitations. In this case, using knee splints helps maintain the leg in an extended position, preventing flexion contractures that commonly affect the knee joints during the healing process. Proper positioning and splinting are essential nursing interventions to preserve joint function and mobility in burn patients.

After a burn injury, the body responds by producing granulation tissue, followed by scar formation. Without proper interventions, scar tissue tends to shorten over time, particularly if the joint is immobilized in a flexed position. This leads to joint contractures, which can permanently limit movement and compromise the patient’s ability to perform activities of daily living (ADLs).

Think of a burn-injured leg like a new elastic band. If the band is left in a bent (flexed) position for too long, it will lose its ability to stretch back to its original shape. Splints act as a mold to keep the leg in the right position, ensuring it stays flexible and functional as it heals.

Preventing contractures involves a combination of splinting, range-of-motion (ROM) exercises, and patient education to promote mobility and proper positioning.

• Apply knee splints as prescribed, ensuring they are adjusted for comfort and proper alignment.
• Perform passive and active range-of-motion exercises several times a day to promote flexibility and prevent stiffness.
• Educate the patient about maintaining positions that stretch affected joints and avoid prolonged periods of immobility.
• Collaborate with physical and occupational therapists to develop individualized rehabilitation plans.
• Monitor for signs of discomfort or skin breakdown due to splint use, and adjust care as needed.

✘Incorrect answer options:

Raising the foot of the bed to reduce pressure. While elevating the legs may reduce swelling and improve circulation, it does not specifically prevent contractures. Contracture prevention requires interventions that maintain joint alignment and mobility, such as splinting or ROM exercises.

Extending the patient’s palms beyond their normal position. This intervention is unrelated to burns on the legs. Extending the palms would be relevant for burns on the hands to prevent contractures of the fingers and wrists but is not appropriate for leg burns.

Performing range-of-motion exercises for the shoulders. While ROM exercises are crucial in burn care, performing shoulder exercises will not address contracture prevention in the knees or legs. The focus should be on the joints directly at risk, such as the knees and ankles, in this patient.

EXPLANATION

✔Correct answer:

Higher urine output with lower urine specific gravity. The fluid remobilization phase of burn recovery occurs approximately 48-72 hours after the initial injury. During this phase, fluid begins to shift back from the interstitial spaces into the vascular compartment as capillary integrity is restored. This fluid shift leads to an increase in intravascular volume, resulting in higher urine output as the kidneys excrete excess fluid. Concurrently, the urine specific gravity decreases because the urine is more dilute, reflecting improved hydration and fluid balance.

Key characteristics of the fluid remobilization phase:

• Increased urine output (diuresis) due to the return of intravascular volume.
• Reduced peripheral edema as fluid moves out of the interstitial space.
• Lower urine specific gravity (<1.010) because of dilute urine.
• Stabilization of vital signs, such as improved blood pressure and peripheral pulses.

This phase marks the transition from the acute shock phase, where hypovolemia and third-spacing predominate, to the resolution of fluid imbalances.

Imagine a sponge that was initially soaked and dripping water (interstitial fluid accumulation in the shock phase). In the remobilization phase, the sponge starts releasing the water back into a bowl (vascular system), leading to a controlled flow (urine output).

During the fluid remobilization phase, monitoring is essential to detect any imbalances or complications as the patient transitions toward stabilization.

• Monitor urine output carefully, ensuring it is within the expected range (30-50 mL/hour or higher during diuresis).
• Assess urine specific gravity regularly to evaluate hydration and renal function.
• Monitor electrolyte levels, as fluid shifts can cause imbalances (e.g., sodium and potassium abnormalities).
• Continue assessing vital signs, especially blood pressure and heart rate, to detect signs of hypovolemia or fluid overload.
• Educate the patient and family about this phase and the importance of ongoing monitoring to ensure recovery progresses smoothly.

✘Incorrect answer options:

More peripheral edema and lower blood pressure. These findings are associated with the acute shock phase of burn injury, which occurs immediately after the burn. Peripheral edema and hypotension result from fluid shifts into the interstitial space (third-spacing) and reduced intravascular volume. These symptoms improve as the fluid remobilization phase begins.

Weakened peripheral pulses with delayed capillary refill. Weakened pulses and delayed capillary refill indicate poor perfusion and hypovolemia, which are characteristic of the early shock phase. In the fluid remobilization phase, capillary refill and pulse quality typically improve as intravascular volume is restored.

Reduced serum sodium levels and elevated hematocrit. While reduced serum sodium levels (hyponatremia) may occur during the remobilization phase due to fluid shifts, elevated hematocrit is more indicative of hemoconcentration in the shock phase, when fluid is lost from the vascular compartment. In the remobilization phase, hematocrit often normalizes as vascular volume is replenished.

EXPLANATION

✔Correct answer:

An elevated serum creatinine level. Gentamicin sulfate is a topical antibiotic frequently used in burn wound care to prevent infection. However, it belongs to the aminoglycoside class of antibiotics, which can be nephrotoxic. Absorption of gentamicin through large burn wounds or prolonged use can lead to systemic toxicity, resulting in kidney damage. An elevated serum creatinine level is a hallmark sign of nephrotoxicity, indicating impaired renal function. This finding requires immediate attention to prevent further kidney damage, which could result in acute kidney injury (AKI).

Aminoglycosides, including gentamicin, accumulate in the renal proximal tubule cells, causing cellular damage and reducing the kidneys' ability to filter waste products. Monitoring renal function (e.g., serum creatinine and blood urea nitrogen) is crucial when gentamicin is used, especially in patients with pre-existing kidney impairment or extensive burns.

Imagine your kidneys as a coffee filter. Nephrotoxic medications like gentamicin clog the filter, making it less efficient at cleaning the "water" (blood), which causes waste (creatinine) to build up.

Nurse Clara should act promptly to address nephrotoxicity and prevent worsening renal function.

• Discontinue gentamicin application and notify the healthcare provider immediately.
• Monitor the patient’s renal function by evaluating serum creatinine, blood urea nitrogen (BUN), and urine output.
• Encourage hydration (if not contraindicated) to promote kidney perfusion and reduce the risk of further toxicity.
• Assess for additional signs of nephrotoxicity, such as decreased urine output or electrolyte imbalances (e.g., hyperkalemia).
• Collaborate with the healthcare team to consider alternative topical antibiotics that do not pose a risk for nephrotoxicity.

✘Incorrect answer options:

A rise in wound pain 30 to 40 minutes after the medication is applied. Increased wound pain shortly after medication application may occur due to irritation from topical agents or wound manipulation during dressing changes. However, this is not specific to gentamicin toxicity and does not indicate an adverse reaction.

Development of small, pale pink bumps within the wound bed. The appearance of pink bumps could indicate granulation tissue, which is a normal part of the wound healing process. This finding does not suggest a reaction to gentamicin.

A drop in the patient’s white blood cell count. Gentamicin is not commonly associated with a significant drop in white blood cell count (leukopenia). If leukopenia were observed, it would more likely result from other causes, such as sepsis, chemotherapy, or bone marrow suppression.

EXPLANATION

✔Correct answer:

27% The Rule of Nines is a standardized method used to estimate the Total Body Surface Area (TBSA) affected by burns. It divides the body into regions, with each region assigned a percentage of TBSA based on multiples of nine. This method is crucial in the acute care of burn patients to determine fluid resuscitation needs and the severity of burns.

Here’s the breakdown for the affected areas:  

• Entire Back (Posterior Trunk): The posterior trunk accounts for 18% of TBSA.
• Left Arm: Each arm (including the hand) accounts for 9% of TBSA.

Adding these together gives: 18% (Back) + 9% (Left Arm) = 27% TBSA burned.

Thus, 27% is the correct estimate for the extent of the burns.

Imagine the body as a pie chart divided into different sections. Each section represents a specific percentage of the "pie" (TBSA). The Rule of Nines helps you quickly add up the affected sections to estimate how much of the pie is damaged.

When a patient sustains burns to 27% of their TBSA, immediate and appropriate care is essential to prevent complications such as hypovolemic shock and infection.

• Fluid Resuscitation: Initiate fluid replacement using a formula like the Parkland formula (4 ml x kg x % TBSA burned). Adjust fluids based on urine output and vital signs.
• Pain Management: Administer prescribed analgesics to control severe pain.
• Wound Care: Maintain a sterile environment to prevent infection during burn care and dressing changes.
• Monitor for Shock: Assess for signs of hypovolemic shock, such as low blood pressure, tachycardia, and reduced urine output.
• Emotional Support: Provide psychological support to help the patient cope with the trauma and appearance changes caused by burns.

✘Incorrect answer options:

9%. This calculation significantly underestimates the TBSA affected. It only accounts for the left arm but ignores the burns on the entire back, which alone accounts for 18% TBSA.

18%. This calculation only includes the entire back and neglects the contribution of the left arm (9%).

36%. This calculation overestimates the TBSA affected. It likely includes areas not mentioned in the question, such as the anterior trunk or additional extremities.

EXPLANATION

✔Correct answer:

A consistent urine output exceeding 100 ml per hour. In burn patients receiving critical fluid resuscitation, urine output is the most reliable and measurable indicator of adequate tissue perfusion and effective fluid resuscitation. After a severe burn, patients experience significant fluid shifts due to increased capillary permeability, leading to hypovolemia and the risk of burn shock. Maintaining adequate urine output is essential to ensure proper kidney perfusion and prevent complications such as acute kidney injury (AKI).

The desired urine output in burn patients is typically:

• Adults: 30-50 ml per hour.
• Electrical burns: 75-100 ml per hour to reduce the risk of myoglobinuria and kidney damage from muscle breakdown.

In Tom's case, a urine output consistently exceeding 100 ml per hour suggests that the fluid resuscitation is effective and compensating for the patient's increased needs due to severe burns.

Think of your body as a car engine. Just as oil circulation indicates the engine is running properly, urine output shows that fluids are circulating well, and the "engine" (body) is functioning correctly.

Managing fluid resuscitation in burn patients requires vigilance and precise monitoring to avoid complications such as hypovolemia or fluid overload.

• Monitor urine output hourly and use a Foley catheter for accurate measurements.
• Assess for signs of fluid overload, such as pulmonary edema, while maintaining adequate resuscitation.
• Calculate fluid requirements using formulas like the Parkland formula (4 ml x kg x % TBSA burned).
• Adjust fluid administration based on urine output and vital signs.
• Monitor electrolyte levels (e.g., sodium, potassium) to prevent imbalances caused by large-volume fluid shifts.

✘Incorrect answer options:

A weight gain of 4 pounds (1.8 kilograms) within a 24-hour period. A weight gain in this scenario indicates fluid retention, which could suggest fluid overload rather than effective fluid resuscitation. Fluid overload can lead to complications such as pulmonary edema and must be avoided in burn patients.

Body temperature readings consistently within normal physiological range. While maintaining normothermia is essential in burn care, it is not a primary indicator of adequate fluid resuscitation. Burn patients often have altered thermoregulation due to skin loss, and other factors such as infection or inflammation may affect body temperature independently of fluid status.

An electrocardiogram (ECG) demonstrating stable cardiac rhythms with no arrhythmias. A stable ECG is important for overall cardiac health but is not a direct measure of the adequacy of fluid resuscitation. While electrolyte imbalances from fluid shifts can affect the heart, monitoring urine output remains the gold standard for assessing fluid resuscitation efficacy.

EXPLANATION

✔Correct answer:

To minimize pressure on the donor site. After a skin graft procedure, the donor site (the area where the skin was harvested) requires careful management to ensure proper healing and prevent complications such as delayed healing, infection, or tissue damage. Minimizing pressure on the donor site is critical because pressure can impair blood flow to the area, disrupt the healing process, and increase the risk of pain or discomfort. By positioning the patient to avoid direct pressure on the donor site, Nurse Riley helps maintain adequate circulation and promotes faster epithelialization (skin regrowth).

Think of the donor site as a new patch of grass you’ve planted. If you walk on the grass (apply pressure), it won’t grow properly. Allowing the area to stay undisturbed ensures healthy growth, just as minimizing pressure supports proper healing at the donor site.

To promote healing and prevent complications at the donor site, Nurse Riley should implement the following interventions:

• Positioning: Ensure the donor site is positioned to avoid direct pressure or friction from bedding, clothing, or devices.
• Wound care: Follow the healthcare provider’s dressing recommendations (e.g., non-adherent dressings) to keep the site clean and prevent infection.
• Monitor for complications: Regularly assess the donor site for signs of infection (e.g., redness, swelling, drainage) or delayed healing.
• Pain management: Administer prescribed analgesics as donor sites can be more painful than the grafted site due to exposed nerve endings.
• Nutritional support: Encourage a high-protein, high-calorie diet to support tissue repair and promote faster healing.

✘Incorrect answer options:

To expose the site to air for ventilation. While air exposure may be helpful for some superficial wounds, donor sites are typically dressed to maintain a moist environment, which promotes epithelialization and healing. Exposing the site to air increases the risk of desiccation, delayed healing, and infection.

To position the site in a dependent position. A dependent position (hanging lower than the heart) may increase swelling and venous stasis, which can compromise circulation and impair healing. Elevating the area or keeping it level is preferable to maintain adequate blood flow.

To maintain complete coverage of the donor site. While covering the site with appropriate dressings is necessary, the priority is not merely "complete coverage" but avoiding pressure on the site. Proper dressing management and pressure minimization work together to promote healing.

EXPLANATION

✔Correct answer:

Notify the physician immediately. The absence of bowel sounds in all four quadrants 12 hours post-burn injury is a concerning finding that may indicate the development of paralytic ileus, a common complication in burn patients. Paralytic ileus is the temporary cessation of normal intestinal motility, often caused by the systemic inflammatory response to burns, hypovolemia, or opioid use for pain management.

In burn patients, this condition warrants prompt intervention because a lack of intestinal motility can lead to abdominal distension, delayed nutrient absorption, or even more serious complications such as bowel ischemia or perforation. Nurse Johnson's priority is to notify the physician immediately so further evaluation and treatment (e.g., insertion of a nasogastric tube, bowel rest, or IV fluid replacement) can be initiated.

Think of the intestines like a conveyor belt moving food through the digestive system. When the belt stops moving (paralytic ileus), everything backs up and creates a problem. Just as you'd call for help to fix a broken conveyor belt, the nurse needs to involve the physician promptly to restore proper function.

Nurse Johnson should take the following steps in response to the absence of bowel sounds:

• Notify the physician immediately: This finding requires prompt evaluation to determine the underlying cause and initiate appropriate treatment.
• Assess for additional symptoms: Monitor the patient for signs of paralytic ileus, such as abdominal distension, nausea, vomiting, or lack of bowel movements.
• Monitor fluid balance: Ensure adequate fluid replacement to address potential hypovolemia, which can worsen paralytic ileus.
• Avoid oral intake: Keep the patient NPO (nothing by mouth) until bowel function returns to prevent further complications.
• Prepare for diagnostic procedures: The physician may order imaging studies, such as an abdominal X-ray, or consider inserting a nasogastric tube for decompression.

✘Incorrect answer options:

Administer a laxative to stimulate bowel activity. Laxatives are contraindicated in this scenario because they could worsen complications if a bowel obstruction is present or if the patient has paralytic ileus. Mechanical stimulation of a non-functioning bowel could lead to perforation or further complications.

Encourage oral intake to promote bowel function. Encouraging oral intake is inappropriate for a patient with absent bowel sounds, as it can increase the risk of abdominal distension, nausea, or vomiting. Oral intake is contraindicated until normal bowel activity resumes.

Document the finding as normal and recheck in 24 hours. While mild decreases in bowel activity may occur due to stress or systemic inflammation after a burn, complete absence of bowel sounds is abnormal and requires immediate evaluation. Delaying intervention could lead to severe complications.

EXPLANATION

✔Correct answer:

Auscultate breath sounds over the trachea and main bronchial areas. Drooling and difficulty swallowing in a burn patient are highly concerning for airway compromise. Burns to the face, neck, or upper torso can lead to edema and inflammation of the upper airway, potentially obstructing airflow. The immediate priority is to assess the patency of the airway. Auscultating breath sounds over the trachea and main bronchi allows the nurse to detect stridor (a high-pitched, harsh sound indicative of upper airway obstruction), wheezing, or diminished breath sounds, which would signal a compromised airway. This assessment is crucial for immediate intervention to secure the airway if necessary.

Burns can cause significant edema due to increased capillary permeability and fluid shifts. When burns involve the face and neck, this edema can compress the upper airway structures, including the trachea and larynx. This can lead to partial or complete airway obstruction, resulting in hypoxia and respiratory distress.

Imagine a garden hose (the airway) delivering water (air) to a plant (the lungs). If someone steps on the hose near the faucet (the upper airway), the water flow is restricted or stopped. Listening closely to the hose near the blockage (auscultation) will reveal a hissing or gurgling sound, indicating the obstruction. Similarly, auscultating breath sounds helps identify airway obstruction in a burn patient.

Airway management is the top priority in burn patients, especially those with burns involving the face, neck, or inhalation injuries.

• Auscultate breath sounds frequently, paying close attention to the presence of stridor, wheezing, or diminished breath sounds.
• Monitor for other signs of respiratory distress, such as increased respiratory rate, nasal flaring, use of accessory muscles, and changes in mental status.
• Be prepared for immediate intubation if signs of airway compromise are present. Early intubation is often preferred over waiting for complete obstruction.
• Maintain a patent airway by positioning the patient appropriately (e.g., head-tilt chin-lift or jaw-thrust maneuver if cervical spine injury is suspected).
• Administer humidified oxygen as prescribed.

✘Incorrect answer options:

Evaluate the patient’s level of consciousness and check pupillary responses. While assessing the level of consciousness and pupillary responses is important in a comprehensive neurological assessment, it is not the priority in this situation. The immediate concern is the patient's airway. Addressing a potentially compromised airway takes precedence over other assessments.

Inquire about the last time the patient consumed food or fluids. While obtaining a dietary history is part of a thorough patient assessment, it is not the priority when the patient is exhibiting signs of potential airway compromise. The immediate focus must be on ensuring a patent airway.

Assess abdominal girth and listen for bowel sounds in all quadrants. Assessing abdominal girth and bowel sounds is important for evaluating gastrointestinal function and potential complications related to burns, such as ileus. However, this is not the priority in the presence of drooling and difficulty swallowing, which strongly suggest a potential airway problem.

EXPLANATION

✔Correct answer:

The patient’s oxygen saturation reads 97%. Oxygen saturation (SpO₂) is a critical indicator of respiratory efficiency and sufficiency, as it reflects the amount of oxygen bound to hemoglobin in the blood. A reading of 97% is within the normal range (95-100%), suggesting that the patient’s respiratory system is effectively oxygenating the blood. This measurement directly demonstrates adequate respiratory function and gas exchange, making it the most definitive finding to confirm sufficient respiratory efforts. While other options indicate aspects of respiratory or neurological function, oxygen saturation is the most reliable parameter for assessing respiratory sufficiency.

The oxygen saturation percentage is measured via pulse oximetry, which assesses the ratio of oxygenated hemoglobin to total hemoglobin in peripheral blood. Adequate oxygenation depends on sufficient ventilation (air movement), perfusion (blood flow), and diffusion (gas exchange at the alveolar-capillary membrane). A SpO₂ level of 97% implies these processes are functioning effectively.

Think of oxygen saturation as the fuel gauge in a car. If the gauge (pulse oximeter) reads "full" or near full (97%), the car (body) has sufficient fuel (oxygen) to keep running efficiently. Without this measurement, we cannot be sure the car has enough fuel.

Nurses should continuously monitor and evaluate oxygen saturation as part of routine respiratory assessments to ensure the patient maintains adequate oxygenation and respiratory effort.

• Ensure proper placement and functioning of the pulse oximeter to get accurate readings.
• Assess other signs of respiratory distress, such as cyanosis, tachypnea, or accessory muscle use, as needed.
• Provide supplemental oxygen if the SpO₂ falls below 92% (unless contraindicated).
• Document and report any significant changes in oxygen saturation immediately.
• Encourage the patient to perform deep breathing exercises if there are signs of shallow breathing.

✘Incorrect answer options:

The patient is speaking without difficulty. While speaking without difficulty can indicate that the airway is patent and the patient is not in significant respiratory distress, it does not directly confirm sufficient oxygenation or respiratory efficiency. For example, a patient could speak normally but still have borderline oxygen levels.

The patient is awake, alert, and oriented. This is an indicator of adequate cerebral oxygenation but does not provide direct evidence of sufficient respiratory effort. A patient could be alert and oriented yet have respiratory insufficiency due to compensatory mechanisms or other factors.

The patient’s chest rises and falls without restriction. Observing chest movement suggests that ventilation is occurring, but it does not guarantee adequate gas exchange or oxygenation. A patient could have normal chest movement yet suffer from impaired gas exchange at the alveolar level (e.g., in conditions like pneumonia or pulmonary edema).