Chapter 66: Caring for Clients with Burns

Which of the following is the preferred IV fluid for burn resuscitation?

Lactated Ringer's (LR)

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

Morphine sulfate

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

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 client who is in the acute phase of recovery from a burn injury has yet to experience adequate pain control. What pain management strategy is most likely to meet this client's needs?

A patient-controlled analgesia (PCA) system

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

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."

A burn client is transitioning from the acute phase of the injury to the rehabilitation phase. The client tells the nurse, "I can't wait to have surgery to reconstruct my face so I look like I used to." What would be the nurse's best response?

"That's something that you and your doctor will likely talk about after your scars mature."

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?

27%

How many people die of burn injuries each year in the United States?

3300

A nurse is caring for a client who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis?

Acute Pain

Which complication is common for victims of electrical burns?

Cardiac dysrhythmia

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.

A client with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the client closely for what signs of the onset of burn shock?

Decreased blood pressure

A public health nurse has reviewed local data about the incidence and prevalence of burn injuries in the community. These data are likely to support what health promotion effort?

Education about workplace health threats

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 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 type of burn injury requires skin grafting?

Full-thickness

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

Hoarseness of the voice

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 patient 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 immediately when reviewing laboratory studies?

Hyperkalemia

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 triage nurse in the emergency department (ED) receives a phone call from a frantic father who saw his 4-year-old child tip a pot of boiling water onto her chest. The father has called an ambulance. What should the nurse in the ED receiving the call instruct the father to do?

Immerse the child in a cool bath.

The closed method is the current preferred method of wound management for many reasons. What is not one of those reasons?

It leads to the formation of a hard crust over a burn.

A client's burns are estimated at 36% of total body surface area; fluid resuscitation has been ordered in the emergency department. After establishing intravenous access, the nurse should anticipate the administration of what fluid?

Lactated Ringer's

Which instruction is the most important to give a client who has recently had a skin graft?

Protect the graft from direct sunlight.

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

Pulmonary system

A nurse is aware that after a burn injury and respiratory difficulties have been managed, the next most urgent need is to:

Replace lost fluids and electrolytes.

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.

Leukopenia within 48 hours is a side effect associated with which topical antibacterial agent?

Sulfadiazine, silver (Silvadene)

A patient has a burn injury that has damaged the epidermis. There are no blisters, and the skin is pink in color. This type of burn injury would be documented as which of the following?

Superficial

An emergency department nurse learns from the paramedics that the team is transporting a client who has suffered injury from a scald from a hot kettle. What variables will the nurse consider when determining the depth of burn?

The causative agent

While performing a client's ordered wound care for the treatment of a burn, the client has made a series of sarcastic remarks to the nurse and criticized her technique. How should the nurse best interpret this client's behavior?

The client may be experiencing anger about his circumstances that he is deflecting toward the nurse.

An emergency department nurse has just admitted a client with a burn. What characteristic of the burn will primarily determine whether the client experiences a systemic response to this injury?

The total body surface area (TBSA) affected by the burn

A nurse is developing a care plan for a client with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. What is the best rationale for this intervention?

To prevent contractures

An occupational health nurse is called to the floor of a factory where a worker has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to "cool the burn." How should the nurse cool the burn?

Wrap cool towels around the affected extremity intermittently.

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

a patent airway established.

An emergency department nurse has just received a client with burn injuries brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the client's body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period?

administer iv fluids

When caring for a client with burns, a nurse should change the wound dressing at least once every:

day.

A client has been burned significantly in a workplace accident. Which conditions create the need for intensive care by specifically trained personnel?

hypotension fluid loss fluid shift

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

inflammatory

Which antimicrobials is not commonly used to treat burns?

tetracycline

A client has experienced burns to his upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action?

Assess the client's peripheral pulses distal to the dressing

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

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