Burns

The provider has ordered an escharotomy for a patient because of constriction around the patient's chest. The nurse is teaching the patient and family about the procedure. Which statement by the family indicates a need for additional teaching? (MSIG26-72)

"He doesn't do well under general anesthesia"

The client is scheduled to have a xenograft to a left lower-leg burn. The client asks the nurse, "What is a xenograft?" Which statement by the nurse would be the best response? (5-492-mss) Full-thickness (3-4th degree)- graft

"The graft will come from an animal, probably a pig"

The family reports that the burn patient is unable to perform self-care measures, so someone has been "doing everything for her." The nurse finds that the patient has the knowledge and the physical capacity to independently perform self-care. What is the nurse's best response? (MSIG26-57)

"What has been happening since you were discharged from the hospital?" (communication - assessment)

Which solution will a client most likely receive for fluid replacement in the first 24 hours after a burn injury that covers a large area? (34-666-dav) Emergent - fluid resuscitation

(crystalloid, will correct the volume deficit, sodium ions, and metabolic acidosis that is present in the client with burns) (NS alone is okay, however since burn client would be hyperkalemic, not added Potassium)

The ED nurse is caring for a client admitted with extensive deep partial-thickness and full-thickness burns. Which intervention should the nurse implement? List in order of priority. (26-522-mss) Intervention - prioritization order

Airway is always the first priority - airway might be compromised Start fluid resuscitation before BP drop make more difficult Cover open wounds - prevent intrusion of bacteria Estimate burn area (after airway, fluids, infection prevention) Pain priority but not before above

The nurse is reviewing the laboratory results for several burn patients who are approximately 24 to 36 hours post-injury. What laboratory results related to the fluid remobilization in these patients does the nurse expect to see (MSIG26-65)

Anemia

You are the nurse manager in the burn unit. Which client is best to assign to an RN who has floated from the oncology unit? (General--assignment)

45 year old with infected partial thickness back and chest burns who has a dressing change scheduled.

You have just received the change-of-shift report in the burn unit. Which client requires the most immediate assessment or intervention? (16-71-lac) Intervention - prioritization

45-year-old with partial-thickness leg burns who has a temperature 102.6; and a blood pressure of 98/46mm Hg.

A patient has sustained a relatively large burn. The nurse anticipates that the patient's nutritional requirements may exceed how many kcal/day? (MSIG26-81)

5000

Which patient has the highest risk for a fatal burn injury? (recall younger than 4 and older than 65)

77-year-old man

The nurse is caring for clients on the pediatric unit. An 8-year-old client with second- and third-degree burns on the right thigh is being admitted. The nurse should assign this new client to which of the following roommates? (60-293-kap) Partial (2nd) Full-thickness (3-4rd) - infection risk

A 4-year-old with asthma (not contaminated, therefore lowest risk of cross-contamination)

Pain management for the burn patient is most effective when (Select all that Apply)

A pain rating tool is used to monitor the patient's level of pain The patient is informed about and has some control over the management of the pain A multimodal approach is used (e.g. sustained- release and short-acting opioids, NSAIDs, adjuvant analgesics)

To maintain a positive nitrogen balance in a major burn, the patient must

Eat a high-protein, low- fat, high-carbohydrate diet

know the most common cause of household fires, which prevention strategy would the nurse focus on when teaching about fire safety (Health promotion-primary prevention)

Encourage regular home exit drills

The client with full-thickness burns to 40% of the body, including both legs , is being transferred from a community hospital to a burn center. Which measure should be instituted before transfer? (2-492-mss)

Adequate peripheral circulation to both feet ensured

You are performing a sterile dressing change for a client with infected deep partial-thickness burns of the chest and abdomen. List the steps of the care plan in the order in which each should be accomplished? (4-69-lac) (Intervention - prioritization)

Administer morphine Debride wound Obtain specimens Apply ointment Cover with dressing

At what point does fluid mobilization occur in patients with burns?(MSIG26-74)

After 36 hours when the fluid is absorbed from the interstitial tissue

The client is admitted with full-thickness and partial-thickness burns to more than 30% of the body. The nurse is concerned with the client's nutritional status. Which intervention should the nurse implement? (10-493-mss)

Encourage the client's family to bring favorite foods

A patient is admitted to the burn center with burns to his head and neck, chest and back after an explosion in his garage. On assessment, the nurse auscultates the wheezes throughout the lung sounds are greatly diminished. Which action is the most appropriate for the nurse to take next? (Inhalation--prioritization)

Anticipate the need for 1) endotracheal intubation 2) notify the physician

A therapeutic measure used to prevent hypertrophic scarring during the rehabilitation phase of burn recovery is

Applying pressure garments

What is the primary reason to prevent infection with burn injuries? (Health promotion--secondary prevention)

Avoid Sepsis

The vaso-dilating effects of carbon monoxide in patients with carbon monoxide poisoning causes what clinical manifestation? (Inhalation--assessment)

Cherry red skin color

The nurse writes the nursing diagnosis "Impaired skin integrity related to open burn wounds" Which intervention would be appropriate for this nursing diagnosis? (7-492-mss) Intervention - < infection risk

Clean the client's wounds, body, and hair daily

You have just received a change-of-shift report for the burn unit. Which client should you assess first? (3-69-lac)

Client who has just arrived from the emergency department with facial burns sustained in a house fire

The nurse is applying a dressing to cover a burn on a patient's left leg. What technique does the nurse use? (MSIG26-52) Intervention - wound dressing

Consider the 1) depth of the injury 2) amount of drainage 3) work distal to proximal

The nurse is planning to change the dressing that covers a deep partial-thickness burn of the right lower leg. Which prescribed medication should the nurse administer to the 70-year-old female patient 30 minutes before the scheduled dressing change?

Morphine sulfate

A patient has 25% TBSA burned from a car fire. His wounds have been debrided and covered with a silver-impregnated dressing. The nurse's priority intervention for wound care would be to Assessment - s/s wound infection

Observe the wound for signs of infection during dressing changes

The client comes into the ER in severe pain and reports that a pot of boiling hot water accidently spilled on his lower legs. The assessment reveals blistered, mottled red skin, and both feet are edematous. Which depth of burn should the nurse document? (Partial (deep) 2nd degree)

Deep-partial thickness.

Because of the fluid shifts in burn patients, what effects on cardiac output does the nurse expect to see? (MSIG26-62)

Depressed up to 36 hours after the burn

A patient has been depressed and withdrawn since her injury and has expressed that "life will never be the same." Which nursing intervention best promotes a positive image for this burn patient? (MSIG26-83)

Discussing the possibility of reconstructive surgery with the patient

The nurse caring for a child burned over 20% of her body assists in performing dressing changes on day 5 after the initial injury. The child appears disoriented, has fever of 101F (38.3 C), and is crying in pain. Which of the following nursing interventions would be the MOST appropriate in caring for this client? (Intervention - Prioritization)

Do a complete physical assessment and notify the physician of the findings

A nurse is assessing a client who sustained deep partial-thickness and full-thickness burns over 40% of his body 24 hr ago. Which of the following are findings should the nurse expect? (Select all that Apply) (atiMS75-3) Emergent - early assess

Dyspnea Hyperkalemia Hyponatremia

A patient has severe burns to the anterior surface of the body from a short exposure to high temperatures at a work site furnace. Which area of the body is most vulnerable to a deep burn injury? (Thermal--risk deep burn)

Eye lids

To prevent the complication of Curling's ulcer, what does the nurse anticipate the provider will order? (MSIG26-77)

H2 histamine blockers

What does the process of full-thickness wound healing include? (Select all that Apply) (MSIG26-59) Full-thickness (3-4th degree) - healing

Healing occurs by wound contraction Eschar must be removed Skin grafting may be necessary Fasciotomy may be needed to relieve pressure and allow normal blood flow

The treatment for a client suffering from hypovolemic shock following excessive burns will focus on controlling fluid loss and replacing fluid volume. A nurse should expect the client with burns to receive solutions that expand volume. To pull fluid from the interstitial spaces, which solutions should the nurse prepare? (Select all that Apply) (36-666-dav)

Hespan (hetastarch) Albumin (hespan is a hypertonic volume expander, pulling fluids from the tissues. Albumin is a hypertonic solution, increasing osmotic pressure, pulling fluid into the vascular space)

The ICU burn nurse is developing a nursing care plan for a client with severe full-thickness and deep partial-thickness burns over half the body. Which client problem has priority? (6-492-mss) Full-thickness - infection risk

High risk for infection

As a result of third-spacing, during the acute phase, which electrolyte imbalances may occur. (Select all that Apply) (MSIG26-61)

Hyperkalemia Hyponatremia

A young child is receiving fluid replacement following a partial-thickness burn covering more than 15% of the client's total body surface area. Which indicator should the nurse use to determine the adequacy of fluid resuscitation? (23-225-FEAB) Emergent - fluid resuscitation

Inadequate urine output (blood pressure and capillary refill may remain normal even in state of hypovolemia)

A patient has sustained significant burns which have created a hypermetabolic state. In planning care for this patient, what does the nurse consider? (MSIG26-64)

Increased caloric needs

A nurse is preparing to administer fentanyl to a client who sustained deep partial-thickness and full-thickness burns over 60% of his body 24 hours ago. The nurse should plan to use which of the following routes to administer the medication? (atiMS75-4)

Intravenous

Which statement about the third-spacing or capillary leak syndrome in a patient with severe burns is accurate? (MSIG26-60)

It is a leak of plasma fluids into the interstitial space

A patient was burned on the forearm after tripping and falling against a wood-burning stove. There are currently several small blisters over the burn area. What does the nurse advise the patient to do about the blisters? (MSIG26-1) Intervention - infection prevention

Leave the blisters intact because they protect the wound from infection

A nurse is planning care for an adult client who sustained severe burn injuries. Which of the following interventions should the nurse include in the plan of care? (Select all that Apply)

Limit visitors in the client's room Increase protein intake Restrict fresh flowers in the room

The nurse is caring for a patient with chronic pain associated with an old burn injury. Which non-pharmacologic intervention does the nurse use to help relieve the patient's pain? (MSIG26-75)

Massaging non-burned areas

A patient has sustained a severe burn greater than 30% TBSA. What is the best way to assess renal function in this patient? (MSIG26-70)

Measure urine output and compare this with fluid intake (importance of Intake/Output's)

The nurse is caring for a firefighter who was brought in for burns around the face and upper chest. Airway maintenance for this patient with respiratory involvement includes what action? (inhalation--intervention)

Monitoring for signs and symptoms of upper airway edema during fluid resuscitation.

Which nursing interventions should be included for the client who has full-thickness and deep partial-thickness burns to 50% of the body? (Select all that Apply) Intervention - infection prevention

Perform meticulous hand hygiene Use sterile gloves for wound care Wear gown and mask during procedures Administer antibiotics as prescribed

What is the most effective intervention for preventing transmission of infection to a burn patient? (MSIG26-25) Intervention - infection prevention

Performing hand hygiene correctly and when appropriate

The nurse is caring for a burn patient about to undergo hydrotherapy. Which complementary therapies are appropriate for pain management in this patient? (Select all that Apply) (MSIG26-49)

Playing music in the background Use of meditative breathing Use of guided imagery

What is the most essential patient data needed for calculating the fluid rates, energy requirements, and drug doses for the burn patient? (MSIG26-79)

Pre-burn weight

The client has full-thickness burns to 65% of the body, including chest area. After establishing a patent airway, which collaborative intervention is priority for the client? (3-492-mss) Emergent - fluid resuscitation

Replace fluid and electrolytes

A patient is recovering from second- and third-degree burns over 30% of his body and is now ready for discharge. The first action the nurse should take when meeting with the patient would be to

Review the patient's current health care status and readiness for discharge to home

A client who has extensive blister injuries to the back of both legs caused by exposure to toxic chemicals at work is admitted to the ED. Which ordered intervention will you implement first? (15-71-lac Intervention - Prioritization

Rinse the back and legs with 4L of sterile normal saline

Fluid and electrolyte shifts that occur during the early Emergent phase of a burn injury include Emergent - fluid shift

Sequestering of sodium and water in the interstitial fluid

A patient with burn injuries is being discharged from the hospital. What important points does the nurse include in the discharge teaching? (Select all that Apply). (MSIG26-63)

Signs and symptoms of infection Drug regimens and potential medication side effects Correct application and care of pressure garments Dates for follow-up appointments

Which drug therapy reduces the risk of wound infection for burn patients? (MSIG26-80)

Silver sulfadiazine (Silvadene) on full-thickness injuries every 4 hours

The injury that is least likely to result in a full thickness burn is.... (Superficial--first degree)

Sunburn

A nurse in a provider's office is assessing a client who has a severe sunburn. Which of the following classifications should the nurse use to document this burn? (Superficial--first degree)

Superficial-thickness

The nurse is caring for a patient who has 30% total body surface area (TBSA) burn. During the first 12 to 36 hours, the nurse carefully monitors the patient for which status changes related to capillary leak syndrome? (MSIG26-2)

Tachycardia and hypotension

The client is being discharged after being in the burn unit for six (6) weeks. Which strategies should the nurse identify to promote the client's mental health? (12-493-mss)

Tell the client to remember that changes in lifestyle take time

Which vaccine is routinely administered when a burn patient is administered to the hospital? (Health promotion--primary prevent)

Tetanus

The 84 year old female client is admitted with multiple burn marks on the torso and under the breasts along with contusions in various stages of healing. When questioned by the nurse, the women denies any problems have occurred. The woman lives with her son and does the housework. Which is the most probable reason the woman is being abused. (Health promotion--abuse.)

The client is ashamed to being abused.

A nurse who is assessing intake and output for a client with severe burn notes that the client's intake is 2,00o ml greater than output. Which rationales should the nurse associate with this discrepancy? (Select all that Apply) Emergent - fluid shift

The client is experiencing vasoconstriction The client is experiencing increased insensible output The client is experiencing third spacing

The nurse is caring for a client with deep partial-thickness and full-thickness burns to the chest area. Which assessment data would warrant notifying the health-care provider (HCP)? (9-493-mss) Report - HCP

The client's urinary output is 50mL in two (2) hours (< 30ml/hr)

The nurse is applying mafenide acetate (Sulfamylon) a sulfa antibiotic cream, to a client's lower extremity burn. Which assessment data would require immediate attention by the nurse? (4-492-mss)

The clients ABGs are pH 7.34; Pao2 98; Paco2 38, and HCO3 20. (sulfamylon is a strong carbonic anhydrase inhibitor that may reduce renal buffering and can cause metabolic acidosis. The ABGs indicate metabolic acidosis and there require immediate intervention)

A nurse knows that the choice of a topical antimicrobial for a client with burns is most influenced by:

The presence and extent of eschar formation (eschar is devitalized tissue, the topical agent must be able to penetrate eschar and not be systemically toxic)

The nurse is caring for a 46-year-old female patient during the first 12 hours after a thermal burn injury. She weighed 71kg on admission to the burn unit. Which outcome if observed by the nurse would indicate adequate fluid resuscitation? (Select all that apply) Emergent - fluid resuscitation

Urine output is 80mL/hr Heart rate is 86 beats/min Urine specific gravity is 1.025

The nurse has just received report on a patient admitted for steam inhalation and burns. The patient is alert and conversant, but reports that his throat feels raw. His wife says that he sounds hoarse compared to as usual. Considering these findings, which order should the nurse question? (Inhalation--hoarse)

Vital signs and airway assessment EVERY SHIFT

A burn patient must have pressure dressings applied to prevent contractures and reduce scarring. For maximum effectiveness, what procedure pertaining to the pressure garments is implemented? (MSIG26-56)

Worn at least 23 hours a day until the scar tissue matures (video states "...one year"

Which patient should the nurse prepare to transfer to a regional burn center? (General--burn center)

a 53 year old patient with a chemical burn to the anterior chest and neck.

The nurse is caring for clients in the ED of an acute care facility. Four clients have been admitted in the last 20 minutes. Which of the following admissions should the nurse see FIRST? (Full-thickness (3rd degree) airway)

a client with third-degree burns to the face

A 28 year old male patient sustained 2nd and 3rd degree burns on his legs (30 percent) when his clothing caught fire while he was burning leaves. He was hosed down by his neighbor and has arrived at the ED in severe discomfort. What is the priority problem for this patient at this time? (Intervention--pain)

acute pain related to damaged or exposed nerve endings.

The nurse is providing emergent care for a 62 year old man with a possible inhalation injury sustained in a house fire. The patient is anxious and disoriented and the skin is a cherry red color. Which action should the nurse take first? (Inhalation--carbon monoxide)

administer 100% humidified oxygen.

Several patients are transported from an industrial fire to a local ED. Which factors increase the risk of death for these patients' would be a SATA. (Assess--mortality risk)

age greater than 60 years burn greater than 40 percent TBSA Presence of an inhalation injury

The home health nurse is visiting an older couple for the initial unit. In observing the household, the nurse identifies several behaviors and environmental factors to address. Which identified factors increase the risk for burns and or household fires? (this would be a SATA) (Health promotion--risk prevention)

ashtray with old cigarette butts on the bedside table space heater very close to the bed single smoke detector in the kitchen back exit hall of the house used as storage space

When assessing a patient with a partial thickness burn, the nurse would expect to find? would be a SATA (partial (deep) 2nd degree)

blisters intact nerve endings red, shiny, wet appearance

A nurse is caring for a client who has sustained burns over 35% of his TBSA. Of this total, 20% are full-thickness burns on the arms, face, neck, and shoulders. The client's voice has a brassy cough and is drooling. The nurse should identify these findings as indicators that the client has which of the following? (Inhalation--brassy cough)

inhalation injury

A patient with a burn injury had an autograph. The nurse learns in report that the donor site is on the upper thigh. What type of wound does the nurse expect to find at the donor site? (partial thickness--dermatome)

partial-thickness

The nurse is caring for a patient who sustained carbon monoxide poisoning while working on his car engine in an enclosed space. What assessment finding does the nurse anticipate? (Inhalation--carbon monoxide)

patient will report headache

The client sustained a hot grease burn to the right hand and calls the emergency room for advice. Which information should the nurse provide to the client? (General-intervention)

place the hand in cool water

Which feelings are most typically expressed by the burn patient would be a select all (Communication--grief/adapting)

regression denial anger

The nurse is caring for a patient brought to the ED after bending over the engine of his car when it exploded in his face. What is the priority for this patient? (Inhalation--prioritization)

secure the airway (think ABC's)

Local tissue resistance to electricity varies in different parts of the body. Which tissues has the most resistance? (Electrical--resistance)

skin epidermis

The nurse is caring for a 34 year old male patient who sustained a deep partial thickness burn to the anterior chest area during work place accident 6 hours ago. Which assessment findings would the nurse identify as congruent with this type of burn? (Partial (deep) 2nd degree)

the skin is... shiny red clear, fluid filled blisters