Chapter 57: Management of Patients with Burn Injury

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?

1

A client has undergone grafting following a burn injury. The nurse understands that the first dressing change at the site of an autograft is performed how soon after the surgery?

2 to 5 days after surgery

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?

2,400 mL

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? You Selected:

2,400 mL

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?

36%

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.

7:30 p.m. to 9:30 p.m.; 24 to 36 hours

The nurse is planning the care of a patient with a major thermal burn. What outcome will the nurse understand will be optimal during fluid replacement?

A urinary output of 30 mL/hr

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 urine output consistently above 40 ml/hour

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?

Application of ice

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

Epidermis and a portion of deeper dermis.

A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern?

BUN: 28 mg/dL

Which complication is common for victims of electrical burns?

Cardiac dysrhythmia

What quick assessment technique should the nurse use to assess the percentage of burn injury?

Compare the client's palm with the size of the burn wound

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?

Electrical burns usually follow an internal path.

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately?

Hoarseness of the voice

A client presents with a full-thickness burn to the anterior chest. The leathery skin is tight, making breathing difficult. The nurse anticipates which treatment management technique in the care of this client?

Escharotomy

The nurse in the emergency department receives a patient who sustained a severe burn injury. What is the priority action by the nurse in this situation?

Establish a patent airway.

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

Fluid resuscitation

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?

Full-thickness

Which zone of burn injury sustains the most damage?

Inner; The inner area (known as the zone of coagulation, where cellular death occurs) sustains the most damage. The middle area, or zone of stasis, has a compromised blood supply, inflammation, and tissue injury. The outer zone, the zone of hyperemia, sustains the least damage.

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?

Instruct to pat and not scratch the areas.

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?

Lactated Ringer's solution

A young child is being evaluated for an area of burn involvement. The nurse knows the most accurate method of assessing the total body surface area is through the use of which assessment tool?

Lund and Browder method

A patient will be receiving biologic dressings. The nurse understands that biologic dressings, which use skin from living or recently deceased humans, are known by what name?

Homografts

A child tips a pot of boiling water onto his bare legs. The mother should:

Immerse the child's legs in cool water.

Which is the primary reason for placing a client in a horizontal position while smothering flames are present?

To keep fire and smoke from airway

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?

Urine output of 20 ml/hour

Which of the following is the analgesic of choice for burn pain?

Morphine sulfate

Which of the following is a disadvantage of surgical debridement?

bleeding

The nurse determines which statement reflects current research regarding the utilization of nonpharmacological measures in the management of burn pain?

Music therapy may provide reality orientation, distraction, and sensory stimulation.

The nurse is caring for a patient who sustained a major burn. What serious gastrointestinal disturbance should the nurse monitor for that frequently occurs with a major burn?

Paralytic ileus

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.

Place the client in a horizontal position. Roll the client in a blanket to smother the fire.

The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to

decrease catabolism.

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?

Preexisting conditions

A client brought to the emergency department has been exposed to smoke and flames from a house fire. What assessment finding is most important to the nurse in determining care of the client?

Presence of soot around nasal passages

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.

This medication is an antibacterial." "This medication will be applied directly to the wound." "This medication will help my burn heal."

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?

Related to circumferential eschar

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?

Roll the client in a blanket.

Which type of burn injury requires skin grafting?

full thickness

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?

full thickness (third degree)

A client who was severely burned begins to exhibit symptoms of renal failure during treatment. What physiologic process can cause acute renal failure?

hemoconcentration

A client who has been burned significantly is taken by air ambulance to the burn unit. What physiologic process furthers a burn injury?

inflammatory

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:

pain management.

The open method (exposure method) of burn care, which exposes the burned areas to air, has been virtually abandoned since the advent of effective topical antimicrobials. It is still used on a small scale however. On which areas of the body are burns still being treated this way? Select all that apply.

the face the perineum

Acticoat antimicrobial barrier dressings used in the treatment of burn wounds can be left in place for which time frame?

5 days

A client is scheduled for an allograft to a burn wound, and the client asks for an explanation. What information will the nurse include in the client teaching?

"An allograft is a temporary wound covering obtained from cadaver skin."

As the first priority of care, a patient with a burn injury will initially need:

a patent airway established.

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?

"Are the burns associated with chemicals used in the plant?"

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?

"As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help."

A client with a burn over the lower leg asks why surgery is planned to remove the dead burned tissue. Which response will the nurse make?

"It reduces the risk of complications from an infection."

A nurse knows to assess a patient with a burn injury for gastrointestinal complications. Which of the following is a sign that indicates the presence of a paralytic ileus?

Decreased peristalsis

A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned?

27%

In a client with burns on the legs, which nursing intervention helps prevent contractures?

Applying knee splints

The nurse provides care for a client with a full-thickness, circumferential burn of the left lower leg. During the nurse's initial shift assessment, the client is resting and the physical assessment of the left lower extremity is unremarkable. One hour later, the nurse notes the pulses of the left lower leg cannot be obtained by a Doppler ultrasound device, and the capillary refill of the left great toe is greater than 2 seconds. What is the nurse's best response based on the clinical findings?

Contact the primary care provider and prepare for an escharotomy.

The nurse is caring for a patient who sustained a full-thickness burn to his arm when he was scalded with boiling water. How did the nurse determine that the patient's burns are full-thickness burns?

Identification by the destruction of the dermis and epidermis

A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client?

Gastric ulcers

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?

Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel.

The nurse cares for a client with extensive burn injuries. Which parameter(s) would the nurse evaluate to determine if the client is receiving adequate fluid resuscitation? Select all that apply.

Heart rate Urine output

A nurse provides care for a client with deep partial-thickness burns 48 hours after the burn. What would cause a reduced hematocrit in this client?

Hemodilution

The nurse recognizes that which of the following provide clues about fluid volume status? Select all that apply.

Hourly urine output Daily weights Skin turgor

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?

Hyperkalemia

Which of the following is to be expected soon after a major burn? Select all that apply.

Hypotension Tachycardia Anxiety

The nurse receives a client following a serious thermal burn. Which complication will the nurse take action to prevent first?

Hypovolemia

Which of the following types of shock will a nurse observe in a client with extensive burns?

Hypovolemic shock

When a client is receiving 100% oxygen, what is the key sign of onset of acute respiratory distress syndrome?

Hypoxemia

The nurse is administering an analgesic to a patient with major burns. What is the recommended route for administration for this patient?

Intravenous

A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene?

Irrigate the wounds with water.

Which of the following is the effect of protein catabolism in a client with severe burns?

It compromises wound healing and immunocompetence.

Which type of debridement occurs when nonliving tissue sloughs away from uninjured tissues?

Natural

A client with superficial burns on the face and deep partial-thickness burns on the neck and chest is undergoing treatment and is anxious to know about skin grafting. For which of the following areas can skin grafting be suggested?

Neck and chest

Following a burn injury, the nurse determines which area is the priority for nursing assessment?

Pulmonary system

Which of the following is a true statement regarding the purposes of skin grafts?

Reduces scarring and contractures.

Which of the following fluid or electrolyte changes occur in the emergent/resuscitative phase?

Reduction in blood volume

Which intervention helps to minimize the risk of further injury to an affected person at the scene of a fire?

Roll the client in a blanket

A nurse is required to monitor the effectiveness of fluid resuscitation in a client who is being treated for burns. Which of the following assessments would indicate the success of the fluid resuscitation?

The client's urinary output is 0.5 to 1 mL/kg/hour.

When the area of burn is irregular in shape and is scattered over multiple areas of the body, which is the best method for the nurse to obtain a quick assessment of the total body surface area of the burn?

Use client's palm size

Following a burn, the nurse understands that the focused management of which burn zone is of greatest concern?

Zone of stasis

A client has received significant electrical burns in a workplace accident. What occurrence makes it difficult to assess internal burn damage in electrical burns?

deep tissue cooling

A nurse is caring for a client with skin grafts covering full-thickness burns on the arms and legs. During dressing changes, the nurse should:

wrap elastic bandages distally to proximally on dependent areas.