CH 57: Management of Patients with Burn Injury

A client has a third-degree burn on the leg. The wound is being treated by the open method. After about 4 days, a hard crust has formed around the leg and is impairing the circulation to the leg. What procedure would be done to relieve pressure on the affected area? A) debridement B) escharotomy C) silvadene application D) allograft

B

The nurse is caring for a client who has sustained severe burns to 50% of the body. The nurse is aware that fluid shifts during the first week of the acute phase of a burn injury cause massive cell destruction. What should the nurse report if it occurs immediately after burn injury? A) Hypercalcemia B) Hyperkalemia C) Hypernatremia D) Hypokalemia

B

The nurse recognizes that which of the following provide clues about fluid volume status? Select all that apply. A) Percentage of meals eaten B) Daily weights C) Skin turgor D) Oxygen saturation E) Hourly urine output

B, C, and E

A child tips a pot of boiling water onto his bare legs. The mother should: A) Avoid touching the burned skin and take the child to the nearest emergency department. B) Liberally apply butter or shortening to the burned areas. C) Immerse the child's legs in cool water. D) Cover the child's legs with ice cubes secured with a towel.

C

A client is brought to the ED with burns exceeding 20% of total body surface area. Which is the primary nursing intervention in the care of this client A) Endotracheal tube placement B) Strict intake and output C) Fluid resuscitation D) Prevent infection

C

A client recovering from burn injuries over both forearms reports itching of the wounds. Which action will the nurse take to enhance the client's comfort? A) Apply warm compresses over the areas. B) Provide pain medication as needed. C) Instruct to pat and not scratch the areas. D) Elevate the extremities above heart level.

C

In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client? A) An electrocardiogram (ECG) showing no arrhythmias B) A weight gain of 4 lb (2 kg) in 24 hours C) A urine output consistently above 40 ml/hour D) Body temperature readings all within normal limits

C

The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to A) increase metabolic rate. B) increase skeletal muscle breakdown. C) decrease catabolism. D) increase glucose demands.

C

Which is the primary reason for placing a client in a horizontal position while smothering flames are present? A) To promote blood flow to the brain and vital organs B) To prevent collapse and further injuries C) To keep fire and smoke from airway D) To extinguish flames more quickly

C

Initial first aid rendered at the scene of a fire includes preventing further injury through heat exposure. Which intervention could contribute to tissue hypoxia and necrosis and therefore should be avoided? A) Irrigation of the wound B) Removal of hair C) Removal of clothing D) Application of ice

D

Determining the depth of a burn is difficult initially because there are combinations of injury zones in the same location. The area of intermediate burn injury is the zone in which blood vessels are damaged, but tissue has the potential to survive. This is called the zone of: A) stasis. B) coagulation. C) hyperemia. D) hypotension.

A

A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem? A) Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg B) Urine output of 20 ml/hour C) White pulmonary secretions D) Rectal temperature of 100.4° F (38° C)

B

An explosion of a fuel tanker has resulted in melting of clothing on the driver and extensive full-body burns. The client is brought into the emergency department alert, denying pain, and joking with the staff. Which is the best interpretation of this behavior? A) The paramedic administered high doses of opioids during transport. B) The client has experienced extensive full-thickness burns. C) The client is in hypovolemic shock. D) The client has experienced partial-thickness burns.

B

The nurse has completed teaching home care instructions to a client being discharged from the burn unit. Which statement from the client indicates the need for further teaching? A) "I will wear sun block with the highest SPF possible to protect exposed burned skin from the sun." B) "As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help." C) "I will drink a lot of fluids to prevent constipation since I am taking pain medications." D) "I can work with the social worker to find funding assistance programs to help with my medical expenses."

B

A client receiving emergency treatment for severe burns has just been assessed to establish the burn depth. Why is a nurse asked to reassess the burn depth after 72 hours? A) The client's condition is likely to deteriorate after 72 hours. B) It helps determine the percentage of the total body surface area (TBSA) that is burned. C) The early appearance of the burn injury may change. D) The wound is susceptible to infections.

C

Which type of debridement occurs when nonliving tissue sloughs away from uninjured tissues? A) Mechanical B) Enzymatic C) Natural D) Surgical

C

Which type of graft utilizes the client's own skin for wound coverage? A) Slit graft B) Heterograft C) Autograft D) Allograft

C

A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned? A) 36% B) 45% C) 18% D) 27%

D

A nurse practitioner administers first aid to a patient with a deep partial-thickness burn on his left foot. The nurse describes the skin involvement as the: A) Epidermal layer only. B) Entire dermis and subcutaneous tissue. C) Dermis and connective tissue. D) Epidermis and a portion of deeper dermis.

D

Following a burn injury, the nurse determines which area is the priority for nursing assessment? A) Pulmonary system B) Pain C) Nutrition D) Cardiovascular system

A

A client is cared for in a burn unit after suffering partial-thickness burns. The client's laboratory work reveals a positive wound culture for gram-negative bacteria. The health care provider orders silver sulfadiazine to be applied to the client's burns. The nurse provides information to the client about the medication. Which statement made by the client indicates an understanding about this treatment? Select all that apply. A) "This medication is an antibacterial." B) "This medication will help my burn heal." C) "This medication will be applied directly to the wound." D) "This medication will stain my skin permanently."

A, B, and C

Which type of burn is similar to a sunburn? A) Electrical B) Superficial partial-thickness C) Deep partial-thickness D) Full-thickness

B

A client who has been burned significantly is taken by air ambulance to the burn unit. What physiologic process furthers a burn injury? A) neuroendocrine B) intravascular fluid excess C) inflammatory D) hypertension

C

A client with a superficial partial-thickness solar burn (sunburn) of the chest, back, face, and arms is seen in urgent care. The nurse's primary concern should be: A) fluid resuscitation. B) infection. C) body image. D) pain management.

D

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which IV fluid does the nurse plan to administer first? A) Lactated Ringer's solution B) Dextrose 5% in water (D5W) C) Albumin D) Normal saline solution with 20 mEq of potassium per 1,000 ml

A

A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene? A) Irrigate the wounds with water. B) Insert a 20-gauge I.V. catheter and infuse normal saline solution at 150 ml/hour. C) Do nothing until the chemical agent is identified. D) Wash the wounds with soap and water and apply a barrier cream.

A

A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body? A) 27% B) 36% C) 18% D) 9%

A

A nurse is aware that after a burn injury and respiratory difficulties have been managed, the next most urgent need is to: A) Replace lost fluids and electrolytes. B) Measure hourly urinary output. C) Prevent renal shutdown. D) Monitor cardiac status.

A

As the first priority of care, a patient with a burn injury will initially need: A) a patent airway established. B) an indwelling catheter inserted. C) fluids replaced. D) pain medication administered.

A

Burn shock is characterized by which of the following? A) Capillary leak B) Elevated blood pressure (BP) C) Organ hyperperfusion D) Severe hypervolemia

A

Several temporary and permanent sources are available for covering a burn wound. These may be manufactured synthetically, obtained from a biologic source, or a combination of the two. Which graft is described as a biologic source of skin similar to that of the client? A) allograft B) xenograft C) slit graft D) autograft

A

The nurse is providing wound care for a client with burns to the lower extremities. Which topical antibacterial agent carries a side effect of leukopenia that the nurse should monitor for within 48 hours after application? A) Sulfadiazine, silver (Silvadene) B) Gentamicin sulfate C) Cerium nitrate solution D) Mafenide (Sulfamylon)

A

The nurse knows that inflammatory response following a burn is proportional to the extent of injury. Which factor presents the greatest impact on the ability to modify the magnitude and duration of the inflammatory response in a client with a burn? A) Preexisting conditions B) Age C) Family history D) Weight

A

When using the Palmer method to estimate the extent of a small or scattered burn injury, the nurse recognizes the palm is equal to which percentage of total body surface area? A) 1 B) 2 C) 3 D) 4

A

Which complication is common for victims of electrical burns? A) Cardiac dysrhythmia B) Inhalation injury C) Infection D) Hypovolemic shock

A

Which of the following is the analgesic of choice for burn pain? A) Morphine sulfate B) Demerol C) Tylenol with codeine D) Fentanyl

A

At the scene of a fire, the first priority is to prevent further injury. What are interventions at the site that can help to prevent injury? Select all that apply. A) Place the client in a horizontal position. B) Roll the client in a blanket to smother the fire. C) Place the client in a vertical position. D) Open a door and encourage air in an enclosed space.

A and B

The nurse is preparing to provide wound care to a client with extensive burns. Which characteristic of the dressing will the nurse use to select the type of topical therapy? Select all that apply. A) Penetrates eschar without toxicity B) Effectiveness against organisms C) Easy to apply and remove to minimize pain D) Used for the duration of the wound care E) Cost-effective and acceptable to the client

A, B, C, and E

Which of the following is to be expected soon after a major burn? Select all that apply. A) Hypotension B) Anxiety C) Hypertension D) Bradycardia E) Tachycardia

A, B, and E

A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned? A) 27% B) 36% C) 30% D) 18%

B

A nurse formulates a nursing diagnosis of Impaired physical mobility for a client with full-thickness burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase? A) Related to infection B) Related to circumferential eschar C) Related to fat emboli D) Related to femoral artery occlusion

B

The nurse participates in a health fair about fire safety. When clothes catch fire, which intervention helps to minimize the risk of further injury to an affected person at a scene of a fire? A) Avoid immediate IV fluid therapy. B) Roll the client in a blanket. C) Place the client with the head positioned slightly below the rest of the body. D) Cover the client with a wet cloth.

B

The spouse of a client who was struck by lightning asks the nurse why the areas involved seems so small but the damage is extensive. Which is the best explanation from the nurse? A) Lightning is higher in voltage than electricity. B) Electrical burns usually follow an internal path. C) Moisture intensifies the damage inflicted. D) The skin is a good conductor of electricity.

B

A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern? A) Na+: 145 mEq/L B) K+: 5.0 mEq/L C) BUN: 28 mg/dL D) Ca: 9 mg/dL

C

A patient is admitted to a burn treatment center at 2:30 p.m. with full-thickness burns over 40% of his body. The injury occurred at 1:30 p.m. at a paper-making plant. The nurse knows that burn shock has to be prevented or treated. Based on fluid volume shifts, the nurse knows that fluid loss would peak by __________ to __________ hours, with the greatest volume being lost from __________ to__________ hours after the burn. A)4:30 p.m. to 6:30 p.m.; 6 to 8 hours B) 10:30 p.m. to 12:30 a.m.; 40 to 50 hours C) 7:30 p.m. to 9:30 p.m.; 24 to 36 hours D) 5:30 p.m. to 6:30 p.m.; 9 to 12 hours

C

A sample consensus formula for fluid replacement recommends that a balanced salt solution be administered in the first 24 hours of a chemical burn in the range of 2 mL/kg/% of burn, with 50% of the total given in the first 8 hours postburn. A 176-lb (80-kg) man with a 30% burn should receive a minimum of how much fluid replacement in the first 8 hours? A) 3,600 mL B) 4,800 mL C) 2,400 mL D) 1,200 mL

C

An emergency department nurse is evaluating a client with partial-thickness burns to the entire surfaces of both legs. Based on the rule of nines, what is the percentage of the body burned? A) 27% B) 9% C) 36% D) 18%

C

Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is: A) Hypoglycemia. B) Hypernatremia. C) Hyperkalemia. D) Hypocalcemia.

C

The nurse receives a client following a serious thermal burn. Which complication will the nurse take action to prevent first? A) Tissue hypoxia B) Renal failure C) Hypovolemia D) Infection

C

What quick assessment technique should the nurse use to assess the percentage of burn injury? A) Check the client's vital signs B) Observe the color of the client's wound C) Compare the client's palm with the size of the burn wound D) Observe the client's level of consciousness

C

Which of the following fluid or electrolyte changes occur in the emergent/resuscitative phase? A) Increased urinary output B) Sodium excess C) Reduction in blood volume D) Potassium deficit

C

Which of the following measures can be used to cool a burn? A) Using cold soaks or dressings for at least 1 hour B) Wrapping the person in ice C) Application of cool water D) Application of ice directly to burn

C

A client has a burn on the leg related to an engine fire. When the burn area was assessed, it was determined that the client felt no pain in the area and that it appeared leathery. How would the nurse document the depth of burn injury this client has? A) superficial partial-thickness or deep partial-thickness (second degree) B) superficial (first degree) C) fourth degree D) full thickness (third degree)

D

A client who has sustained burns to the anterior chest and upper extremities is brought to the burn center. During the initial stage of assessment, which nursing diagnosis is primary? A) Infection Risk B) Altered Tissue Perfusion C) Acute Pain D) Risk for Impaired Gas Exchange

D

A manufacturing plant has exploded, and the nurse is assigned to triage burn victims as they arrive to the hospital. Which is the most important question for the nurse to ask prior to the arrival of victims? A) "Are the victims suffering from thermal burns?" B) "Are any of the victims expected to have electrical burns?" C) "How many victims are anticipated for transport?" D) "Are the burns associated with chemicals used in the plant?"

D

A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following? A) Superficial partial-thickness B) Deep partial-thickness C) Superficial D) Full-thickness

D

A person suffers leg burns from spilled charcoal lighter fluid. A family member extinguishes the flames. While waiting for an ambulance, what should the burned person do? A) Remove his burned pants so that the air can help cool the wound. B) Sit in a chair, elevate his legs, and have someone cut his pants off around the burned area. C) Lie down, have someone cover him with a blanket, and cover his legs with petroleum jelly. D) Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel.

D

In a client with burns on the legs, which nursing intervention helps prevent contractures? A) Performing shoulder range-of-motion exercises B) Elevating the foot of the bed C) Hyperextending the client's palms D) Applying knee splints

D

The palm represents which percentage of a person's TBSA? A) 10% B) 5% C) 15% D) 1%

D

Which of the following is the effect of protein catabolism in a client with severe burns? A) It compromises dexterity and mobility. B) It maximizes the risk of sodium retention and hypotension. C) It maximizes the risk of impaired ventilation. D) It compromises wound healing and immunocompetence.

D