Med Sure Chapter 62: Managements of Patients With Burn Injury second

A nurse helps a health care provider treat a full-thickness burn on a patient's hand. Prior to treatment, the nurse documents the appearance of the wound as:

Dry and pale white.

The nurse is providing care for a patent with a full-thickness, circumferential burn of the left lower leg. During the nurse's initial shift assessment, the patient 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. The nurse's best response based on the clinical findings is which of the following?

Contact the primary care provider and prepare for an escharotomy.

Which is the primary nursing intervention in the care of a client with burns exceeding 20% of total body surface area?

Fluid resuscitation

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 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?"

When using the Palmar method to estimate the extent of a small or scattered burn injury, the palm is equal to which percentage of total body surface area (TBSA)?

1

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

27%

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%

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%

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?

36%

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

A patent airway established.

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

Which of the following measures can be used to cool a burn?

Application of cool water

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

Applying knee splints

A patient with a severe electrical burn injury is being treated in the burn unit. Which of the following laboratory results would cause the nurse the most concern?

BUN: 28 mg/dL

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.

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.

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 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 wait for emergency personnel.

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.

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?

Impaired risk for gas exchange

When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority?

Ineffective airway clearance related to edema of the respiratory passages

In a client who has been burned, which medication should the nurse expect to use to prevent infection?

Mafenide (Sulfamylon)

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

Morphine sulfate

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.

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?

Risk for Impaired Gas Exchange

The nurse is participating in a health fair about fire safety. Which of the following interventions helps to minimize the risk of further injury to an affected person at a scene of a fire when clothes catch fire?

Roll the patient in a blanket.

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

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?

The early appearance of the burn injury may change.

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?

The client has experienced extensive full-thickness burns.

A nurse is preparing a care plan for a client burned over 36% of his body 2 days previously. Which clinical manifestation indicates that the client has progressed into the intermediate phase of burn care?

The client's complete blood count readings reflect a reduced hematocrit.

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 0.3 to 0.5 mL/kg/hour.

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?

escharotomy

Specific potential complications are common to specific types of burns. Which burns can impair ventilation? perineal face, neck, chest hands, major joints All options are correct.

face, neck, chest

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 charred. What depth of burn injury does the client have?

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

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

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 zone of burn injury sustains the most damage?

inner

Which antimicrobials is not commonly used to treat burns?

tetracycline

The nurse has completed teaching home care instructions to a patent being discharged from the burn unit. Which of the following patient statements indicates the need for further teaching?

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

The most important intervention in the nutritional support of a patient with a burn injury is to provide adequate nutrition and calories to promote which of the following?

Decreased catabolism

Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction which is:

Hyperkalemia.

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

Hypotension Tachycardia Anxiety

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

The nurse is caring for a patient in the burn unit. Which of the following may be an early sign of sepsis in the patient with burn injury?

Narrowing pulse pressure

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

Natural

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

Zone of stasis

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.

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 consists of the area where the injury is most severe and deepest?

Coagulation

Which type of burn injury requires skin grafting?

Full-thickness

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

Reduces scarring and contractures.

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