Burns, Skin, & Immune Exam 3

The nurse asks the student nurse, "What does it mean that an antibiotic is classified as a bactericidal agent?" Which response by the nursing student indicates an understanding of a bactericidal agent? 1. Has low efficacy 2. Has a very low potency 3. Kills the infectious agent 4. Slows the growth of the infectious agent

3. Kills the infectious agent IGGY page 445 446

The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instructions? 1. "I should take hot baths because they are relaxing." 2. "I should sit whenever possible to conserve my energy." 3. "I should avoid long periods of rest because it causes joint stiffness." 4. "I should do some exercises, such as walking, when I am not fatigued."

1. "I should take hot baths because they are relaxing." Rationale: To help reduce fatigue in the client with systemic lupus erythematosus, the nurse should instruct the client to sit whenever possible, avoid hot baths (because they exacerbate fatigue), schedule moderate low-impact exercises when not fatigued, and maintain a balanced diet. The client is instructed to avoid long periods of rest because it promotes joint stiffness. IGGY page 345

Coal tar has been prescribed for the client with psoriasis, and the nurse provides instructions to the client regarding this treatment. Which statement by the client indicates a need for further instruction? 1. "The medication can cause diarrhea." 2. "The medication can cause phototoxicity." 3. "The medication has an unpleasant odor." 4. "The medication can stain the skin and hair."

1. "The medication can cause diarrhea." Rationale: Coal tar is used to treat psoriasis and other chronic disorders of the skin. It suppresses DNA synthesis, mitotic activity, and cell proliferation. It has an unpleasant odor, frequently can stain the skin and hair, and can cause phototoxicity. It does not cause diarrhea.

The emergency department nurse is caring for a client who has sustained chemical burns to the esophagus after ingestion of lye. The nurse reviews the health care provider's prescriptions and should plan to question which prescription? 1. Gastric lavage 2. Intravenous (IV) fluid therapy 3. Nothing by mouth (NPO) status 4. Preparation for laboratory studies

1. Gastric lavage Rationale: The client who has sustained chemical burns to the esophagus is placed on NPO status, is given IV fluids for replacement and treatment of possible shock, and is prepared for esophagoscopy and barium swallow to determine the extent of damage. Laboratory studies also may be prescribed. A nasogastric tube may be inserted, but gastric lavage and emesis are avoided to prevent further erosion of the mucosa by the irritating substances that these treatments involve.

The nurse is reviewing the laboratory test results for a client admitted to the burn unit 3 hours after an explosion that occurred at a worksite. The client has a severe burn injury that covers 35% of the total body surface area (TBSA). The nurse is most likely to note which finding on the laboratory report? 1. Hematocrit 60% 2. Serum albumin 4.8 g/dL 3. Serum sodium 144 mEq/L 4. White blood cell (WBC) count 9000 cells/mm3

1. Hematocrit 60% Rationale: Extensive burns greater than 25% of the TBSA result in generalized body edema in both burned and unburned tissues and a decrease in circulating intravascular blood volume. Hematocrit levels are elevated in the first 24 hours after injury as a result of hemoconcentration from the loss of intravascular fluid. The normal hematocrit level ranges from 42% to 52%, IGGY page 524

The nurse has provided discharge instructions to a client who has had cryosurgery to remove a malignant skin lesion. The nurse determines that the client understands the instructions if the client makes which statement? Select all that apply. 1. "I need to avoid baths or showers for 7 to 10 days." 2. "I need to clean the site as prescribed to prevent infection." 3. "I need to apply ice to the site continuously to prevent swelling." 4. "I need to expect some swelling and tenderness in the affected area." 5. "I need to apply alcohol-soaked dressings twice a day for 30 minutes each time.

2. "I need to clean the site as prescribed to prevent infection." 4. "I need to expect some swelling and tenderness in the affected area." IGGY page 504

The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse develops a postoperative plan of care for the client and should include which intervention in the plan? 1. Maintain the client in a prone position. 2. Elevate and immobilize the grafted extremity. 3. Maintain the grafted extremity in a flat position. 4. Keep the grafted extremity covered with a blanket.

2. Elevate and immobilize the grafted extremity. Rationale: Autografts placed over joints or on lower extremities are elevated and immobilized following surgery for 3 to 7 days, depending on the surgeon's preference. This period of immobilization allows the autograft time to adhere and attach to the wound bed, and the elevation minimizes edema. Keeping the client in a prone position and covering the extremity with a blanket can disrupt the graft site. IGGY page 533

The nurse is caring for a client who sustained a thermal burn caused by the inhalation of steam 24 hours ago. The nurse determines that the priority nursing action is to assess which item? 1. Pain level 2. Lung sounds 3. Ability to swallow 4. Laboratory results

2. Lung sounds Rationale: The priority nursing action would be to assess lung sounds. Thermal burns to the lower airways can occur with the inhalation of steam or explosive gases or with the aspiration of scalding liquids. Thermal burns to the upper airways are more common and cause erythema and edema of the airways and mucosal blisters or ulcerations. The mucosal edema can lead to upper airway obstruction, particularly during the first 24 to 48 hours after burn injury. IGGY page 521

A nurse is assessing a dark-skinned client for the presence of petechiae. Which body area is the best for the nurse to check in this client? 1. Sclera 2. Oral mucosa 3. Soles of the foot 4. Palms of the hand

2. Oral mucosa IGGY page 863

A client is seen in the ambulatory care clinic for a superficial burn to the arm. On assessing the skin at the burn injury, what will the nurse observe? 1. White color 2. Pink or red color 3. Weeping blisters 4. Insensitivity to pain and cold

2. Pink or red color Rationale: Superficial burns are pink or red without any blistering. The skin blanches to touch, may be edematous and painful, and heals on its own, usually within 1 week. A white color characterizes deep partial-thickness burns. Weeping blisters characterize partial-thickness superficial burns. Deep full-thickness burns are associated with insensitivity to pain and cold IGGY page 513

An adult client trapped in a burning house has suffered burns to the back of the head, upper half of the posterior trunk, and the back of both arms. Using the rule of nines, what does the nurse determine the extent of the burn injury to be? Fill in the blank.

22.5% Rationale: According to the rule of nines, the posterior side of the head equals 4.5%, the back of both arms equals 9%, and the upper half of the posterior trunk equals 9%, totaling 22.5% IGGY page 523

A burn client has been having 1% silver sulfadiazine applied to burns twice a day for the last 3 days. Which laboratory abnormality indicates that the client is experiencing an adverse effect of this medication? 1. Serum sodium of 120 mEq/L 2. Serum potassium of 3.0 mEq/L 3. White blood cells of 3000 cells/mm3 4. pH 7.30, Pco2 of 35 mm Hg, HCO3- of 19 mEq/L

3. White blood cells of 3000 cells/mm3 Rationale: Transient leukopenia typically occurs after 2 to 3 days of treatment. Knowing this and knowing normal white blood cell values will direct you to option 3. IGGY page 534

The nurse in the ambulatory care unit is providing home care instructions to a client after cryotherapy for the treatment of malignant skin lesions. Which statement would be most appropriate for the nurse to include in the home care instructions for this client? 1. "Apply ice to the site to prevent swelling." 2. "Clean the site with alcohol three times daily." 3. "Apply a warm, damp washcloth if discomfort occurs." 4. "Avoid showering or taking baths until seen by the health care provider in 1 week."

3. "Apply a warm, damp washcloth if discomfort occurs." IGGY page 504

An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury?

36% Rationale: According to the rule of nines, with the initial burn, the anterior half of the head equals 4.5%, the upper half of the anterior torso equals 9%, and the lower half of both arms equals 9%. The subsequent burn included the posterior half of head, equaling 4.5%, and the upper half of posterior torso, equaling 9%. This totals 36%

A 60-kg client has sustained third-degree burns over 40% of the body. Using the Parkland (Baxter) formula, the minimum fluid requirements are which during the first 24 hours after the burn? 1. 1200 mL of 5% dextrose in water solution 2. 2400 mL of 0.45% normal saline solution 3. 4800 mL of 0.9% normal saline solution 4. 9600 mL of lactated Ringer's solution

4. 9600 mL of lactated Ringer's solution Rationale: The Parkland (Baxter) formula is 4 mL of lactated Ringer's solution × kg body weight × percent burn. The calculation is performed as follows: 4 mL × 60 kg × 40 = 9600 mL. IGGY page 526

The nurse is reviewing the discharge instructions for the client who had a skin biopsy. Which statement, if made by the client, would indicate a need for further instruction? 1. "I will keep the dressing dry." 2. "I will watch for any drainage from the wound." 3. "I will use the antibiotic ointment as prescribed." 4. "I will return tomorrow to have the sutures removed."

4. "I will return tomorrow to have the sutures removed." IGGY page 468

The nurse is providing instructions to a client with psoriasis who will be receiving ultraviolet light (UVL) therapy. Which statement would be most appropriate for the nurse to include in the client's instructions? 1. "Each treatment will last at least 30 minutes." 2. "Your entire body will be exposed to the light treatment." 3. "You will need to wear cotton clothes during the treatment." 4. "You will need to wear dark eye goggles during the treatment."

4. "You will need to wear dark eye goggles during the treatment." Rationale: Safety precautions are required during UVL therapy. Protective dark eye goggles are required to prevent exposure of the eyes to the UVL; it may be necessary to wear the goggles for the remainder of the day following treatment. The face also is shielded with a loosely applied cloth if it is unaffected by the psoriasis. Most UVL therapies require the client to stand in a light treatment chamber for up to a maximum of 15 minutes. The client will not wear clothing on the body parts to be exposed and will expose only those areas requiring treatment to the UVL. Direct contact with the light bulbs used for the treatment should be avoided to prevent burning of the skin. IGGY page 500

A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the client? 1. 100% oxygen via an aerosol mask 2. Oxygen via nasal cannula at 6 L/minute 3. Oxygen via nasal cannula at 15 L/minute 4. 100% oxygen via a tight-fitting, nonrebreather face mask

4. 100% oxygen via a tight-fitting, nonrebreather face mask Rationale: If an inhalation injury is suspected, administration of 100% oxygen via a tight-fitting nonrebreather face mask is prescribed until carboxyhemoglobin levels fall (usually below 15%). In inhalation injuries, the oropharynx is inspected for evidence of erythema, blisters, or ulcerations. The need for endotracheal intubation also is assessed.

In planning care for the client with psoriasis, the nurse understands that which represents a priority client problem? 1. Fatigue 2. Constipation 3. Impaired safety 4. Altered body image

4. Altered body image IGGY page 500 501

Blood work has been drawn on a client who has been taking cyclosporine (Sandimmune) following allogenic liver transplantation. The nurse should check the results of which test to determine the presence of an adverse effect related to this medication? 1. Hematocrit level 2. Cholesterol level 3. Hemoglobin level 4. Blood urea nitrogen (BUN) level

4. Blood urea nitrogen (BUN) level Rationale: Nephrotoxicity is one of the most common adverse effects of cyclosporine. Nephrotoxicity is evaluated by monitoring the BUN and creatinine levels.

The nurse is monitoring the fluid balance of a client with a burn injury. The nurse determines that the client is less than adequately hydrated if which information is noted during assessment? 1. Urine pH of 6 2. Urine that is pale yellow 3. Urine output of 40 mL/hr 4. Urine specific gravity of 1.032

4. Urine specific gravity of 1.032 Rationale: The client who is not adequately hydrated will have an elevated urine specific gravity. Normal values for urine specific gravity range from approximately 1.016 to 1.022. Pale yellow urine is a normal finding, as is a urine output of 40 mL/hr (minimum is 30 mL/hr). A urine pH of 6 is adequate (4.5 to 8.0 normal), and this value is not used in monitoring hydration status.

The nurse is instructing a client about the management of systemic sclerosis. Which statement indicates that the client requires additional teaching? a. "I will let my doctor know right away if I develop a fever." b. "Ice packs will help relieve the aching pain in my hips and knees." c. "I will wear mittens when I am in the freezer section of the grocery store." d. "I will apply a rich moisturizer to my skin every morning after my shower."

ANS: B Ice packs should not be used by clients with systemic sclerosis because the cold can trigger symptoms of Raynaud's phenomenon. The client should wear mittens whenever his or her hands are exposed to cold temperatures, and moisturizer should be applied daily. The client should notify the doctor if a fever develops.

A client who is being evaluated for thermal burn injuries to the arms and legs complains of thirst and asks the nurse for a drink. Which action by the nurse is most appropriate? 1. Keep the client on NPO status. 2. Allow the client to have full liquids. 3. Give the client small glasses of clear liquids. 4. Order the client a full meal tray with extra liquids.

1. Keep the client on NPO status. Rationale: The client should be maintained on NPO status because burn injuries frequently result in paralytic ileus. The client also should be told that fluids could cause vomiting because of the effect of the burn injury on gastrointestinal tract functioning. Mouth care should be given as appropriate to alleviate the sensation of thirst.

Which individual is least likely to be at risk for development of psoriasis? 1. A 32-year-old African American 2. A woman experiencing menopause 3. A client with a family history of the disorder 4. An individual who has experienced a significant amount of emotional distress

1. A 32-year-old African American Rationale: Psoriasis is a chronic, noninfectious skin inflammation involving keratin synthesis that results in psoriatic patches. Various forms exist, with psoriasis vulgaris being the most common type. Possible causes of the disorder include stress, trauma, infection, hormonal changes, obesity, an autoimmune reaction, and climate changes; a genetic predisposition may also be a cause. The disorder also may be exacerbated by the use of certain medications. Psoriasis occurs equally among women and men, although the incidence is lower in darker-skinned races and ethnic groups. IGGY page 498 499

A burn-injured client is receiving treatments of topical mafenide acetate (Sulfamylon) to the site of injury. The nurse should monitor the client for which systemic effect that can occur from the use of this medication? 1. Acidosis 2. Alkalosis 3. Hypotension 4. Hypertension

1. Acidosis Rationale: Mafenide acetate is a carbonic anhydrase inhibitor and can suppress renal excretion of acid, thereby causing acidosis. Clients receiving this treatment should be monitored for acidosis, and if the acidosis becomes severe, the medication should be discontinued for 1 to 2 days. An elevated blood pressure may be expected in the client with pain.

When assessing a lesion diagnosed as malignant melanoma, the nurse most likely expects to note which finding? 1. An irregularly shaped lesion 2. A small papule with a dry, rough scale 3. A firm, nodular lesion topped with crust 4. A pearly papule with a central crater and a waxy border

1. An irregularly shaped lesion Rationale: A melanoma is an irregularly shaped pigmented papule or plaque with a red-, white-, or blue-toned color.

The nurse is applying a topical glucocorticoid as prescribed for a client with psoriasis. The nurse would be least concerned about the potential for systemic absorption of the medication if it were being applied to which body area? 1. Back 2. Neck 3. Scalp 4. Axilla

1. Back Rationale: Topical glucocorticoids can be absorbed into the systemic circulation. Absorption is higher from regions where the skin is especially permeable (scalp, axilla, face, eyelids, neck, perineum, genitalia) and lower from regions where penetrability is poor (back, palms, soles).

A burn client is receiving treatments of topical mafenide acetate (Sulfamylon) to the site of injury. The nurse monitors the client, knowing that which finding indicates that a systemic effect has occurred? 1. Hyperventilation 2. Local rash at the burn site 3. Elevated blood pressure 4. Local pain at the burn site

1. Hyperventilation Rationale: Mafenide acetate is a carbonic anhydrase inhibitor and can suppress renal excretion of acid, thereby causing acidosis. Clients receiving this treatment should be monitored for signs of an acid-base imbalance (hyperventilation). If this occurs, the medication will probably be discontinued for 1 to 2 days. Options 2 and 4 describe local rather than systemic effects. An elevated blood pressure may be expected from the pain that occurs with a burn injury. Kee Hayes page 756 757

The nurse is preparing to perform an assessment on a client being seen in the clinic. On review of the client's record, the nurse notes that the client has psoriasis. The nurse would expect to observe which characteristics on assessment of the client's psoriatic lesions? Select all that apply. 1. Red, raised papules 2. Large plaques covered by silvery scales 3. Tiny red vesicles that weep serous material 4. Erythema noted mostly under the breast area 5. Pink to dark red, patchy eruptions on the skin

1. Red, raised papules 2. Large plaques covered by silvery scales IGGY page 499

The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy? 1. Return of distal pulses 2. Brisk bleeding from the site 3. Decreasing edema formation 4. Formation of granulation tissue

1. Return of distal pulses Rationale: Escharotomies are performed to relieve the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential third-degree burn. Escharotomies are performed through avascular eschar to subcutaneous fat. Although bleeding may occur from the site, it is considered a complication rather than an anticipated therapeutic outcome. Usually, direct pressure with a bulky dressing and elevation control the bleeding, but occasionally an artery is damaged and may require ligation

A client is diagnosed with scleroderma. Which intervention should the nurse anticipate to be prescribed? 1. Maintain bed rest as much as possible. 2. Administer corticosteroids as prescribed for inflammation. 3. Advise the client to remain supine for 1 to 2 hours after meals. 4. Keep the room temperature warm during the day and cool at night

2. Administer corticosteroids as prescribed for inflammation. Rationale: Scleroderma is a chronic connective tissue disease similar to systemic lupus erythematosus. Corticosteroids may be prescribed to treat inflammation. Topical agents may provide some relief from joint pain. Activity is encouraged as tolerated and the room temperature needs to be constant. Clients need to sit up for 1 to 2 hours after meals if esophageal involvement is present. IGGY page 347 348

Ultraviolet (UV) light therapy is prescribed as a component of the treatment plan for a client with psoriasis, and the nurse provides instructions to the client regarding the treatment. Which statement by the client indicates a need for further instructions? 1. "Treatments are limited to two or three times a week." 2. "The UV light treatments are given on consecutive days." 3. "Eye goggles need to be worn to prevent exposure to UV light." 4. "Just the area requiring treatment should be exposed to the UV light."

2. "The UV light treatments are given on consecutive days." Rationale: UV light treatments are limited to two or three times a week and are not given on consecutive days. Safety precautions are required during UV light therapy. It is best to expose only those areas requiring treatment to the UV light. Protective wraparound goggles prevent exposure of the eyes to UV light. The face should be shielded with a loosely applied pillow case if it is unaffected. Direct contact with the light bulbs of the treatment unit should be avoided to prevent burning of the skin. IGGY page 500

A client scheduled for a skin biopsy is concerned and asks the nurse how painful the procedure is. Which statement is the appropriate response by the nurse? 1. "There is no pain associated with this procedure." 2. "The local anesthetic may cause a burning or stinging sensation." 3. "A preoperative medication will be given so you will be sleeping and will not feel any pain." 4. "There is some pain, but the health care provider will prescribe an opioid analgesic after the procedure."

2. "The local anesthetic may cause a burning or stinging sensation." IGGY page 468

A client is brought to the emergency department with partial thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply. 1. Restrict fluids. 2. Assess for airway patency. 3. Administer oxygen as prescribed. 4. Place a cooling blanket on the client. 5. Elevate extremities if no fractures are present. 6. Prepare to give oral pain medication as prescribed.

2. Assess for airway patency. 3. Administer oxygen as prescribed. 5. Elevate extremities if no fractures are present. Rationale: The primary goal for a burn injury is to maintain a patent airway, administer IV fluids to prevent hypovolemic shock, and preserve vital organ functioning. Therefore the priority actions are to assess for airway patency and maintain a patent airway. The nurse then prepares to administer oxygen. Oxygen is necessary to perfuse vital tissues and organs. An IV line should be obtained and fluid resuscitation started. The extremities are elevated to assist in preventing shock. The client is kept warm and placed on NPO status because of the altered gastrointestinal function that occurs as a result of a burn injury.

A client who previously suffered a burn injury now exhibits a keloid at the burn site. The nurse plans care, knowing that this lesion is caused by hypertrophy of which part of the dermis? 1. Nerves 2. Collagen 3. Vasculature 4. Subcutaneous tissue

2. Collagen IGGY page 501 502

A client with a burn injury is applying mafenide (Sulfamylon) to the wound. The client calls the health care provider's office and tells the nurse that the medication is uncomfortable and is causing a burning sensation. The nurse should instruct the client to take which action? 1. Discontinue the medication. 2. Continue with the treatment, as this is expected. 3. Apply a thinner film than prescribed to the burn site. 4. Come to the office to see the health care provider (HCP) immediately.

2. Continue with the treatment, as this is expected. Rationale: Mafenide is used to treat partial- and full-thickness burns. It is bacteriostatic for both gram-negative and -positive organisms present in avascular tissues. The client should be warned that the medication will cause local discomfort and burning. The nurse does not instruct a client to alter a medication prescription IGGY page 534

The health education nurse provides instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which instructions should the nurse provide? Select all that apply. 1. Sunscreen should be applied every 8 hours. 2. Use sunscreen when participating in outdoor activities. 3. Wear a hat, opaque clothing, and sunglasses when in the sun. 4. Avoid sun exposure in the late afternoon and early evening hours. 5. Examine your body monthly for any lesions that may be suspicious.

2. Use sunscreen when participating in outdoor activities. 3. Wear a hat, opaque clothing, and sunglasses when in the sun. 5. Examine your body monthly for any lesions that may be suspicious. Rationale: The client should be instructed to avoid sun exposure between the hours of 10 am and 4 pm. Sunscreen, a hat, opaque clothing, and sunglasses should be worn for outdoor activities. The client should be instructed to examine the body monthly for the appearance of any possible cancerous or any precancerous lesions. Sunscreen should be reapplied every 2 to 3 hours and after swimming or sweating; otherwise, the duration of protection is reduced IGGY Page 503

The nurse is reviewing discharge instructions for a client who had a skin biopsy. Which statement by the client indicate a need for further instruction? 1. "I will use the antibiotic ointment as prescribed." 2. "I will return in 7 days to have the sutures removed." 3. "I will remove the dressing as soon as I get home and wash it with tap water." 4. "I will call the health care provider (HCP) if I see any drainage from the wound."

3. "I will remove the dressing as soon as I get home and wash it with tap water." Rationale: After a skin biopsy, the nurse instructs the client to keep the dressing dry and in place for a minimum of 8 hours. After the dressing is removed, the site is cleaned once daily with tap water or saline to remove any dry blood or crusts. The HCP may prescribe an antibiotic ointment to minimize local bacterial colonization. The nurse instructs the client to report any redness or excessive drainage at the site. Sutures usually are removed 7 to 10 days after biopsy. IGGY page 468

Silver sulfadiazine (Silvadene, Thermazene, SSD cream) is prescribed for a client with a partial-thickness burn and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments? 1. "The medication is an antibacterial." 2. "The medication will help heal the burn." 3. "The medication will permanently stain my skin." 4. "The medication should be applied directly to the wound."

3. "The medication will permanently stain my skin." Rationale: Silver sulfadiazine (Silvadene, Thermazene, SSD cream) is an antibacterial that has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. It is applied directly to the wound to assist in healing. It does not stain the skin.

The nurse is providing care for a client who sustained burns over 30% of the body from a fire. On assessment, the nurse notes that the client is edematous in both burned and unburned body areas. The nurse documents this assessment finding as expected because the edema is caused by which factor? 1. A decrease in capillary permeability and hypoproteinemia 2. A decrease in capillary permeability and hyperproteinemia 3. An increase in capillary permeability and hypoproteinemia 4. An increase in capillary permeability and hyperproteinemia

3. An increase in capillary permeability and hypoproteinemia Rationale: In extensive burn injuries (greater than 25% of total body surface area), the edema occurs in both burned and unburned areas as a result of the increase in capillary permeability and hypoproteinemia. Edema also may be caused by the volume and oncotic pressure effects of the large fluid resuscitation volumes required

The nurse is performing an assessment on a client who sustained circumferential burns of both legs. Which assessment would be the initial priority in caring for this client? 1. Assessing heart rate 2. Assessing respiratory rate 3. Assessing peripheral pulses 4. Assessing blood pressure (BP)

3. Assessing peripheral pulses Rationale: The client who receives circumferential burns to the extremities is at risk for altered peripheral circulation. The priority assessment would be to assess for peripheral pulses to ensure that adequate circulation is present. Although the respiratory rate and BP also would be assessed, the priority with a circumferential burn is the assessment for the presence of peripheral pulses. IGGY page 515

A client with psoriasis is being treated with calcipotriene (Dovonex) cream. Administration of high doses of this medication can cause which adverse effect? 1. Alopecia 2. Hyperkalemia 3. Hypercalcemia 4. Thinning of the skin

3. Hypercalcemia Rationale: Calcipotriene (Dovonex), an analogue of vitamin D3, is indicated for mild to moderate psoriasis. Responses are equal to those achieved with medium-potency topical glucocorticoids. The most common adverse effect is local irritation. Unlike glucocorticoids, calcipotriene does not cause thinning of the skin. At high doses, calcipotriene has caused hypercalcemia. Alopecia and hyperkalemia is not associated with this medication Kee Hayes page 751

A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mm Hg, a pulse rate of 110 beats/minute, and a urine output of 20 mL over the past hour. The nurse reports the findings to the health care provider (HCP) and anticipates which prescription? 1. Transfusing 1 unit of packed red blood cells 2. Administering a diuretic to increase urine output 3. Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour 4. Changing the IV lactated Ringer's solution to one that contains dextrose in water

3. Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour Rationale: Fluid management during the first 24 hours following a burn injury generally includes the infusion of (usually) lactated Ringer's solution. Fluid resuscitation is determined by urine output and hourly urine output should be at least 30 mL/hour. The client's urine output is indicative of insufficient fluid resuscitation, which places the client at risk for inadequate perfusion of the brain, heart, kidneys, and other body organs. Therefore the HCP would prescribe an increase in the amount of IV lactated Ringer's solution administered per hour. IGGY page 526 & 257

Mafenide acetate (Sulfamylon) is prescribed for a client with a burn injury. When applying the medication, the client complains of local discomfort and burning. The nurse should take which most appropriate action? 1. Discontinue the medication. 2. Notify the health care provider. 3. Inform the client that this is expected 4. Apply a thinner film than prescribed to the burn site.

3. Inform the client that this is expected Rationale: Mafenide acetate is bacteriostatic for gram-negative and gram-positive organisms and is used to treat burns to reduce bacteria present in avascular tissues. The client should be informed that the medication will cause local discomfort and burning and that this is a normal reaction. Kee Hayes page 757

A client returns to the clinic for follow-up treatment following a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that melanoma has which characteristic? 1. Metastasis is rare. 2. It is encapsulated. 3. It is highly metastatic. 4. It is characterized by local invasion.

3. It is highly metastatic. Rationale: Melanomas are pigmented malignant lesions originating in the melanin-producing cells of the epidermis. This skin cancer is highly metastatic, and a person's survival depends on early diagnosis and treatment. IGGY page 502

When monitoring initial fluid replacement for the patient with 40% TBSA deep partial-thickness and full-thickness burns, which finding is of most concern to the nurse? a. Serum K+ of 4.5 mEq/L b. Urine output of 35 mL/hr c. Decreased bowel sounds d. Blood pressure of 86/72 mm Hg

Answer: d Rationale: Adequacy of fluid replacement is assessed by urine output and cardiac parameters. Urine output should be 0.5 to 1 mL/kg/hr. Mean arterial pressure should be >65 mm Hg, systolic BP >90 mm Hg, and heart rate <120 beats/min. A blood pressure of 86/72 indicates inadequate fluid replacement. However, the MAP is calculated at 77 mm Hg.

An erythrocyte sedimentation rate (ESR) determination is prescribed for a client with a connective tissue disorder. The client asks the nurse about the purpose of the test. What should the nurse tell the client about the purpose of the test? 1. Determines the presence of antigens 2. Identifies which additional tests need to be performed 3. Confirms the diagnosis of a connective tissue disorder 4. Confirms the presence of inflammation or infection in the body

4. Confirms the presence of inflammation or infection in the body Rationale: The ESR can confirm the presence of inflammation or infection in the body. It is particularly useful for the management of connective tissue disease because the rate measured directly correlates with the degree of inflammation and later with the severity of the disease. IGGY page 336

A client is receiving topical corticosteroid therapy for the treatment of psoriasis. The nurse anticipates noting which health care provider's prescription in the client's medical record that will maximize the effectiveness of this therapy? 1. Rub the application into the skin. 2. Place the area under a heat lamp for 20 minutes. 3. Apply a dry sterile dressing over the affected area. 4. Cover the application with a warm, moist dressing and an occlusive outer wrap.

4. Cover the application with a warm, moist dressing and an occlusive outer wrap. IGGY page 499 500

A complete blood cell count is performed in a client with systemic lupus erythematosus (SLE). The nurse would suspect that which finding will be noted in the client with SLE? 1. Decreased platelets only 2. Increased red blood cell count 3. Increased white blood cell count 4. Decreased number of all cell types

4. Decreased number of all cell types Rationale: In the client with SLE, a complete blood count commonly shows pancytopenia, a decrease in the number of all cell types. This finding is most likely caused by a direct attack of all blood cells or bone marrow by immune complexes. IGGY page 345

The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury? 1. Decreased heart rate 2. Increased urinary output 3. Increased blood pressure 4. Elevated hematocrit levels

4. Elevated hematocrit levels Rationale: The resuscitation/emergent phase begins at the time of injury and ends with the restoration of capillary permeability, usually at 48 to 72 hours following the injury. During the resuscitation/emergent phase, the hematocrit level increases to above normal because of hemoconcentration from the large fluid shifts. Hematocrit levels of 50% to 55% are expected during the first 24 hours after injury, with return to normal by 36 hours after injury. Initially, blood is shunted away from the kidneys, and renal perfusion and glomerular filtration are decreased, resulting in low urine output. Pulse rates are typically higher than normal, and the blood pressure is decreased as a result of the large fluid shifts. IGGY page 524

A client is diagnosed with a full-thickness burn. The nurse understands that which structural areas of the skin are involved? 1. Epidermis only 2. Epidermis and deeper dermis 3. Epidermis and upper layer of dermis 4. Epidermis, entire dermis, and epithelial portion of subcutaneous fat

4. Epidermis, entire dermis, and epithelial portion of subcutaneous fat Rationale: A full-thickness burn involves the epidermis, entire dermis, and epithelial portion of subcutaneous fat layer. Option 1 describes a superficial burn. Option 2 describes a deep partial-thickness burn. Option 3 describes a partial-thickness burn. IGGY Page 513

The nurse is performing an assessment on a client who was admitted with a diagnosis of carbon monoxide poisoning. Which assessment performed by the nurse would primarily elicit data related to a deterioration of the client's condition? 1. Skin color 2. Apical rate 3. Respiratory rate 4. Level of consciousness

4. Level of consciousness Rationale: The neurological system is primarily affected by carbon monoxide poisoning. With high levels of carbon monoxide, the neurological status progressively deteriorates. Although options 1, 2, and 3 would be a component of the assessment of the client with carbon monoxide poisoning, assessment of the neurological status of the client would elicit data specific to a deterioration in the client's condition. IGGY page 522

The clinic nurse assesses the skin of a client with a diagnosis of psoriasis. The nurse understands that which characteristic is associated with this skin disorder? 1. Oily skin 2. Clear, thin nail beds 3. Red-purplish scaly lesions 4. Silvery-white scaly patches

4. Silvery-white scaly patches Rationale: Psoriatic patches are covered with silvery white scales. Affected areas include the scalp, elbows, knees, shins, sacral area, and trunk. Thickening, pitting, and discoloration of the nails occur. Pruritus may occur. IGGY page 498-499

The nurse is caring for a client who was admitted to the burn unit after sustaining a burn injury covering 30% of the body. What is the most appropriate time frame for the emergent phase? 1. The entire period of time during which rehabilitation occurs 2. The period from the time the client is stable until all burns are covered with skin 3. The period from the time the burn was incurred to the time when the client is admitted to the hospital 4. The period from the time the burn was incurred to the time when the client is considered physiologically stable

4. The period from the time the burn was incurred to the time when the client is considered physiologically stable Rationale: The emergent phase of burn care generally extends from the time the burn injury is incurred until the time when the client is considered physiologically stable. The acute phase lasts until all full-thickness burns are covered with skin. The rehabilitation period lasts approximately 5 years for an adult and includes reintegration into society. IGGY page 513

A client sustains a burn injury to the entire right and left arms, the right leg, and the anterior thorax. According to the rule of nines, the nurse would assess that this injury constitutes which body percentage? Fill in the blank.

54% Rationale: According to the rule of nines, the right arm is equal to 9% and the left arm is equal to 9%. The right leg is equal to 18% and the left leg is equal to 18%. The anterior thorax is equal to 18% and the posterior thorax is equal to 18%. The head is equal to 9% and the perineum is equal to 1%. If the anterior thorax, the right leg, and right and left arm were burned, according to the rule of nines, the total area involved would be 54%

A patient with partial-thickness wounds of the face and chest caused by a campfire is admitted to the burn unit. All of these actions have been prescribed by the physician. Which one should the nurse accomplish first? A) Give oxygen per non-rebreather mask at 100% FiO2. B) Infuse lactated Ringer's solution at 150 mL/hr. C) Give morphine sulfate 4 to 10 mg IV for pain control. D) Insert a 14-Fr retention catheter.

A) Give oxygen per non-rebreather mask at 100% FiO2.

When providing care for a client with an acute burn injury, which nursing intervention is most important to prevent infection by autocontamination? A. Change gloves between wound care on different parts of the client's body. B. Avoid sharing equipment such as blood pressure cuffs between clients. C. Use proper and consistent handwashing by all members of the staff. D. Use the closed method of burn wound management for all wound care.

A. Change gloves between wound care on different parts of the client's body. Autocontamination is the transfer of microorganisms from one area to another area of the same client's body, causing infection of a previously uninfected area. Although all techniques listed can help reduce the risk for infection, only changing gloves between carrying out wound care on different parts of the client's body can prevent autocontamination.

Which intervention is most important to use to prevent infection by autocontamination in the burned client during the acute phase of recovery? A. Changing gloves between wound care on different parts of the client's body. B. Avoiding sharing equipment such as blood pressure cuffs between clients. C. Using the closed method of burn wound management. D. Using proper and consistent handwashing

A. Changing gloves between wound care on different parts of the client's body.

The nurse is caring for a client who has dysphagia caused by systemic sclerosis. What is the best intervention for the nurse to implement for this client? a. Encourage frequent, high-protein, easy to swallow foods. b. Teach the client to lie flat after meals to prevent reflux. c. Thicken liquids to a nectar or honey consistency. d. Have the client hyperextend his or her neck while swallowing.

ANS: A Clients with dysphagia frequently have esophageal motility problems, and swallowing becomes difficult. This, combined with malabsorption, leads to a malnourished client. Frequent small meals consisting of high-protein and easy to swallow foods are best. Clients should eat only in an upright position to reduce choking. Thickening liquids may help, but this does not address the malnutrition. Hyperextending the neck may help, but specific techniques should be determined by a swallowing study.

The nurse is instructing a client about management of discoid lupus erythematosus (DLE). Which statement indicates that the client requires additional teaching? a. "I will be sure to apply sunscreen whenever I am outside." b. "I will apply small amounts of the steroid cream to my face twice a day." c. "I will take Plaquenil (hydroxychloroquine sulfate) with breakfast each morning." d. "Steroids weaken the immune system, so I will wash my hands frequently."

ANS: D Steroid creams used for the treatment of discoid lupus will not weaken the immune system because they should be applied in small amounts to affected areas. The client will be more sensitive to sun exposure while using the steroid cream, so sunscreen should be used whenever the client goes outside. The client should use only small amounts of the cream on her face. Plaquenil should be taken with meals or a glass of milk.

A patient who is admitted to a burn unit is hypovolemic. A new nurse asks an experienced nurse about the patient's condition. Which response if made by the experienced nurse is most appropriate? a. "Blood loss from burned tissue is the most likely cause of hypovolemia." b. "Third spacing of fluid into fluid-filled vesicles is usually the cause of hypovolemia." c. "The usual cause of hypovolemia is vaporation of fluid from denuded body surfaces." d. "Increased capillary permeability causes fluid shifts out of blood vessels and results in hypovolemia."

Answer: d Rationale: Hypovolemic shock is caused by a massive shift of fluids out of the blood vessels as a result of increased capillary permeability. Water, sodium, and plasma proteins move into interstitial spaces and other surrounding tissue.

During the emergent phase of burn injury, the nurse assesses for the presence of hypovolemia. In burn patients, hypovolemia occurs primarily as a result of a. Blood loss from injured tissue. b. Third spacing of fluid into fluid-filled vesicles. c. Evaporation of fluid from denuded body surfaces. d. Capillary permeability with fluid shift to the interstitium.

Answer: d Rationale: Hypovolemic shock is caused by a massive shift of fluids out of the blood vessels as a result of increased capillary permeability. Water, sodium, and plasma proteins move into interstitial spaces and other surrounding tissue.

What statement by the client indicates the need for further discussion regarding the outcome of skin grafting (allografting) procedures? A. "For the first few days after surgery, the donor sites will be painful." B. "Because the graft is my own skin, there is no chance it won't 'take'." C. "I will have some scarring in the area when the skin is removed for grafting." D. "Once all grafting is completed, my risk for infection is the same as it was before I was burned."

B. "Because the graft is my own skin, there is no chance it won't 'take'." they are describing autografting which is from another part of your own body

Which statement by a client with psoriasis indicates a need for further teaching? A. "I expect that these patches will get smaller when I lay out in the sun." B. "I have to make sure I keep my lesions covered, so I do not spread this to others." C. "I should continue to use the cortisone ointment as the patches shrink and dry out." D. "At the next family reunion, I'm going to ask my relatives if they have psoriasis."

B. "I have to make sure I keep my lesions covered, so I do not spread this to others." Psoriasis is not a contagious disorder. The client does not have to worry about spreading the condition to others. It is a condition that has hereditary links, and the patches will decrease in size with ultraviolet light exposure.

The client who experienced an inhalation injury 6 hours ago has been wheezing. When the client is assessed, wheezes are no longer heard. What is the nurse's best action? A. Raise the head of the bed. B. Notify the emergency team. C. Loosen the dressings on the chest. D. Document the findings as the only action.

B. Notify the emergency team. If wheezes disappear this indicates impending airway obstruction

A client is 24 hours post burn and has the following laboratory results. Which result does the nurse report to the health care provider immediately? A. Serum sodium, 131 mEq/L B. Serum potassium,7.5 mEq/L C. Hematocrit, 52% D. Arterial pH, 7.32

B. Serum potassium,7.5 mEq/L The serum potassium level is changed to the degree that serious life-threatening responses could result. With such a rapid rise in potassium level, the client is at high risk for experiencing severe cardiac dysrhythmias and death. All the other findings are abnormal but do not show the same degree of severity; they would be expected in the emergent phase after a burn injury.

Which assessment does the nurse prioritize for the client in the acute phase of burn injury? A) Bowel sounds B) Muscle strength C) Signs of infection D) Urine output

C) Signs of infection

The burned client is ordered to receive intravenous cimetidine, an H2 histamine blocking agent, during the emergent phase. When the client's family asks why this drug is being given, what is the nurse's best response? A. "To increase the urine output and prevent kidney damage." B. "To stimulate intestinal movement and prevent abdominal bloating." C. "To decrease hydrochloric acid production in the stomach and prevent ulcers." D. "To inhibit loss of fluid from the circulatory system and prevent hypovolemic shock."

C. "To decrease hydrochloric acid production in the stomach and prevent ulcers."

At what point after a burn injury should the nurse be most alert for the complication of hypokalemia? A. Immediately following the injury B. During the fluid shift C. During fluid remobilization D. During the late acute phase

C. During fluid remobilization Hypokalemia is most likely to occur during the fluid remobilization period as a result of dilution, potassium movement back into the cells, and increased potassium excreted into the urine with the greatly increased urine output.

On assessment, the nurse notes that a client has burns inside the mouth and is wheezing. Several hours later, the wheezing is no longer heard. What is the nurse's next action? A. Raise the head of the bed to a semi-Fowler's position. B. Loosen any constrictive dressings on the chest. C. Gather appropriate equipment and prepare for intubation. D. Document the findings and reassess in 1 hour.

C. Gather appropriate equipment and prepare for intubation. Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose effective movement of air. When this occurs, wheezing is no longer heard, and neither are breath sounds. These clients can lose their airways very quickly, so prompt action is needed. The client requires establishment of an emergency airway. Swelling usually precludes intubation.

Which statement made by the client with facial burns who has been prescribed to wear a facial mask pressure garment indicates correct understanding of the purpose of this treatment? A. "After this treatment, my ears will not stick out." B. "The mask will help protect my skin from sun damage." C. "Using this mask will prevent scars from being permanent." D. "My facial scars should be less severe with the use of this mask."

D. "My facial scars should be less severe with the use of this mask."

When should ambulation be initiated in the client who has sustained a major burn? A. When all full-thickness areas have been closed with skin grafts B. When the client's temperature has remained normal for 24 hours C. As soon as possible after wound debridement is complete D. As soon as possible after resolution of the fluid shift

D. As soon as possible after resolution of the fluid shift

The newly admitted client has burns on both legs. The burned areas appear white and leather-like. No blisters or bleeding are present, and the client states that he or she has little pain. How should this injury be categorized? A. Superficial B. Partial-thickness superficial C. Partial-thickness deep D. Full thickness

D. Full thickness

A client is receiving fluid resuscitation after a burn. Which finding indicates that fluid resuscitation is adequate for this client? A. Heart rate = 130 beats/min B. Hematocrit = 60% C. Increased peripheral edema D. Urine output = 50 mL/hr

D. Urine output = 50 mL/hr The fluid remobilization phase improves renal blood flow, increases diuresis, and restores blood pressure and heart rate, as well as laboratory values, to more normal levels.

A client has experienced an electrical injury of the lower extremities. Which priority assessment data should be obtained from this client? a. Heart rate, rhythm, and electrocardiogram (ECG) b. Range of motion in all extremities c. Orientation to time, place, and person d. Respiratory rate and pulse oximetry

Heart rate, rhythm, and electrocardiogram (ECG) The airway is not at any particular risk with this injury. Therefore, respiratory rate and pulse oximetry are not priority assessments. Electrical current travels through the body from the entrance site to the exit site and can seriously damage all tissues between the two sites. Early cardiac damage from electrical injury includes irregular heart rate and rhythm, and ECG changes. Range-of-motion and neurologic assessments are important; however, the priority is to make sure that the heart rate and rhythm are adequate to support perfusion to the brain and other vital organs.