med surg chapter 66 caring for clients with burns

One major antimicrobial used in the treatment of burns is silver sulfadiazine (Silvadene) ointment. When providing instructions for the use of silver sulfadiazine (Silvadene), which teaching measure should be stressed? A) Cleanse skin prior to application. B) Apply dressing over ointment. C) Apply moderate amounts to burn area. D) Do not apply to newly debrided areas.

Ans: A Feedback:Silver sulfadiazine (Silvadene) does not penetrate so should be used on clean, debrided burn areas. Discharge instructions should include the need to remove old ointment prior to application of new. Silver sulfadiazine (Silvadene) is considered a closed method of treatment and does not require additional dressing application. Silver sulfadiazine (Silvadene) should be applied sparingly using a sterile glove or applicator.

Which zone consists of the area where the injury is most severe and deepest? A) Coagulation B) Stasis C) Hyperemia D) Necrosis

Ans: A Feedback:The zone of coagulation is at the center of the injury and is the area of injury that is most severe and the deepest. The zone of stasis is the area of intermediate burn injury. The zone of hyperemia is the area of least injury, where the epidermis and dermis are only minimally damaged. There is no zone of necrosis.

Which of the following would indicate the need to increase fluids beyond what is recommended for fluid resuscitation? A) Myoglobin in the urine B) Increase in antidiuretic hormone (ADH) C) Elevation of blood glucose levels D) Hypernatremia

Ans: A Feedback: Myoglobin from muscle tissue destruction is transported to the kidneys for excretion and can cause tubular necrosis and acute renal failure. Increase in fluid intake until urine output clears is recommended in serious burns. An increase in ADH release is expected as the body tries to prevent hypovolemic shock. Elevation in glucose levels occurs when the adrenal cortex is stimulated. Sodium levels rise in response to aldosterone levels, which directly leads to peripheral edema.

Which of the following actions should a nurse perform to help reduce the accumulation of debris within the burn wound? A) Use powder-free sterile gloves. B) Use topical antimicrobial medications. C) Use cold compresses or sponges. D) Use sterilized gauze swaps.

Ans: A Feedback: The healthcare team should wear powder-free sterile gloves when handling the burn wound to reduce the accumulation of debris within the wound that may complicate the healing. After the wound has been cleansed, topical antimicrobial medications are used to minimize the risk of infection. The particles or fiber from cold compresses, sponges, or sterilized gauze swaps may add to the accumulation` of debris if used on a burn wound.

After being exposed to smoke and flames from a house fire, which assessment finding is most important in determining care of the client? A) Presence of soot around nasal passages B) Fracture of the fibula with displacement C) Elevation of blood pressure and heart rate D) Partial-thickness burns to hands and wrists

Ans: A Feedback: If the client has soot or evidence of carbon about the nasal passages, the nurse should anticipate respiratory difficulties. Edema and swelling of the internal airways may not be present initially but can progress quickly. Elevation of heart rate without hypotension is not as significant. Fracture to any bone as well as care of burns should be managed once the airway, breathing, and circulation are assessed and managed.

Skin substitutes are often used after the wound is debrided and cleaned. Which of the following supports a primary purpose for the use of a skin substitute? Select all that apply. A) Lessen potential for infection B) Maximizes fluid loss C) Promotes granulation of tissue D) Covers the unattractiveness of the wound E) Slows regeneration of tissue F) Diminishes pain

Ans: A,F Feedback:Skin substitute provides a temporary covering of the burn area and lessens the potential for infection. The covering decreases pain associated with contact and exposure to the air. The covering decreases fluid loss through evaporation and discourages granulation tissue, which contains fibroblasts causing scars. The skin substitute promotes tissue generation and healing.

The spouse of a victim, 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) Electrical burns usually follow an internal path. B) Lightning is higher in voltage than electricity. C) The skin is a good conductor of electricity. D) Moisture intensifies the damage inflicted.

Ans: A Feedback: Electrical current follows the path of less resistance. Because the skin is the most resistant organ, the current follows nerves, blood vessels, and muscles, causing organ damage along the way. Lightning is high-voltage electricity. Presence of water acts as a conductor of electrical current.

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) Risk for Impaired Gas Exchange B) Acute Pain C) Risk for Infection D) Alteration in Tissue Perfusion

Ans: A Feedback:During the initial assessment of a burn victim, the nurse must look for evidence of inhalation injury. Once oxygen saturation and respirations are determined, pain intensity is evaluated. The assessment of damage to the tissues and prevention of infection are secondary to airway issues.

Following a burn to a large area of the body, the client receives an Oasis porcine graft. Which statement by the client indicates an understanding of the use of this grafting material? A) "This graft contains material obtained from a cow." B) "This graft will not become a permanent part of my skin." C) "This graft was applied with a spray gun." D) "This graft was harvested from another human."

Ans: B Feedback: A xenograft, such as Oasis, is a temporary cover that will be rejected in days to weeks and will need to be replaced or removed at that time. A porcine graft originates from a pig. Autologous skin cell isolation grafting requires a 5 × 5 cm sample of skin that is separated and sprayed on the wound. Cadaver skin and or stem cells from umbilical cord blood are grafting material that is harvested from another human.

A young child is being evaluated for 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? A) Rule of nines B) Lund and Browder method C) Hand method D) Parkland formula method

Ans: B Feedback: The Lund and Browder method divides body into smaller segments. Different percentages are assigned to body parts, depending on patient's age. For example, the adult head is equivalent to 9%, whereas the infant head is 19%. This method is more accurate when dealing with children. The rule of nines and hand method are quick assessment techniques for estimating burns. The Parkland formula incorporates fluid resuscitation requirements for burns.

Which of the following is a disadvantage of surgical debridement? A) Scarring B) Bleeding C) Loss of function D) Contractures

Ans: B Feedback:A disadvantage of surgical debridement is bleeding. Scarring, loss of function, and contractures are not disadvantages of surgical debridement.

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) "How many victims are anticipated for transport?" C) "Are the burns associated with chemicals used in the plant?" D) "Are any of the victims expected to have electrical burns?"

Ans: C Feedback:If the victim has sustained chemical burns, the chemicals must be removed from the skin to prevent burns to others, including the triage nurse and emergency staff. Thermal and electrical burn victims do not require special handling considerations. The number of victims expected is not a significant issue for the triage nurse but rather for the external disaster team dispatch personnel.

The client is admitted with full-thickness burn to the forearm. Which is the most accurate interpretation made by the nurse? A) The wound will take up to 3 weeks to heal. B) Pain management will be a challenge. C) Skin grafting will be necessary. D) Ligaments, tendons, muscles, and bone are not involved.

Ans: C Feedback:In a full-thickness burn, all layers of the skin are destroyed and will result in the need for skin grafts. Full-thickness burns are painless. A deep partial-thickness burn may take 3 or more weeks to heal. In the most serious full-thickness burns, ligaments, tendons, muscles, and bone may be involved.

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? A) Endotracheal tube insertion B) Tracheostomy C) Escharotomy D) Ventilator assisted breathing

Ans: C Feedback:In areas of full-thickness burns, eschar constricts the area and can impair circulation or expansion of the anterior chest wall. An escharotomy is performed to release the burn tissue on the anterior chest, freeing the chest for expansion with inspiration. Endotracheal tube insertion, tracheostomy, and ventilation do not correct the tightening of the chest and poor expansion issue.

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) Age B) Weight C) Preexisting conditions D) Family history

Ans: C Feedback:Preexisting disease disorders including trauma and infections can modify the inflammatory response and movement of fluid from the vascular to the interstitial space. Age, weight, and family history are not as significant in the inflammatory response following a burn.

Skin grafts are necessary for which of the following burns? A) Superficial B) Superficial partial thickness C) Full thickness D) First degree

Ans: C Feedback:Skin grafts are necessary for a full-thickness burn because the skin cells no longer are alive to regenerate. Superficial (first degree), superficial partial-thickness burns do not usually need skin grafting.

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? A) Rule of nines B) Use client's palm size C) Parkland formula D) Lund and Browder burns assessment

Ans: B Feedback:A quick assessment technique to use to evaluate an area of burn that is not restricted to one portion of the body is by using the client's palm size to approximate the total body surface. The palm is approximately 1% of a person's TBSA. The Parkland formula determines fluid resuscitation needs. Lund and Browder burns assessment provides a more precise estimate for determining TBSA that is burned and is especially more specific in children. The rule of nines quantitates burns that involve entire sections of the body, not scattered burns.

When providing initial assessment to a client who has suffered an electrical burn, which assessment finding will provide the most important data? A) Size of burn B) Location of entry and exit wounds C) Level of pain D) Amount of fluid replaced

Ans: B Feedback:An electrical burn has two wounds. Entry wound, where the current entered the body, and exit wound, where the current exited the body. The current will take the least resistant path through the body from entry to exit and usually travels along a nerve, muscle, or bone. The location of the two wounds will assist in determining which organs have been impacted while the current traveled through the body. The size, location, and depth of the burn are important in determining extent of injury. Level of pain is an important assessment finding. The amount of fluid replaced is not as important as the response to the fluids. The urine output is paramount in determining adequate fluid hydration following fluid resuscitation.

Which type of skin graft is more comparable in appearance to normal skin? A) Lace graft B) Full-thickness graft C) Slit graft D) Split-thickness graft

Ans: B Feedback:Full-thickness grafts are more comparable in appearance to normal skin and can tolerate more stress once they become permanently attached to the burn wound. A slit graft (lace graft) is used when the area available as a donor site is limited, as in clients with extensive burns. In a split-thickness graft, the epidermis and a thin layer of the dermis are harvested from the client's skin.

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 client is in hypovolemic shock. B) The client has experienced extensive full-thickness burns. C) The paramedic administered high doses of opioids during transport. D) The client has experienced partial-thickness burns.

Ans: B Feedback:In full-thickness burns, nerves are damaged and consequently painless. Behavior change is not a significant symptom of hypovolemic shock. Opioids are used in the management of pain associated with partial-thickness burns but not significant in the behavior exhibited. Partial-thickness burns are associated with increased pain to the area of involvement.

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

Ans: B Feedback:Natural debridement is accomplished when nonliving tissue sloughs away from uninjured tissue. Mechanical debridement occurs when dead tissue adheres to dressings or is detached during cleaning. Enzymatic debridement encompasses the use of topical enzymes to the burn wound. Surgical debridement uses forceps and scissors during dressing changes or wound cleaning.

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? A) The client's heart rate is rapid and regular. B) The client's urinary output is 0.3 to 0.5 mL/kg/hour. C) The client's breathing is unlabored, and skin is clammy. D) The client is alert and conscious.

Ans: B Feedback:Successful fluid resuscitation is gauged by a urinary output of 0.3 to 0.5 mL/kg/hour via an indwelling catheter. Fluid resuscitation does not directly affect the client's heart rate, breathing, or mental status.

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

Ans: B Feedback:The primary reason the client is placed in a horizontal position while smothering flames is to prevent the fire, hot air, and smoke from rising toward the head and entering the respiratory passages. Stop, drop, and roll method is a quick efficient means to distinguish flames. If hypovolemic shock occurs, lowering the head will assist in promoting blood flow to the head.

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

Ans: B Feedback: Fluid resuscitation requirements are paramount in the management of clients having burns that exceed 20% of TBSA. Fluid resuscitation with crystalloid and colloid solutions is calculated from the time the burn injury occurred to restore the intravascular volume and prevent hypovolemic shock and renal failure. Infection prevention is a care consideration with all burns. Endotracheal tube placement may be necessary if respiratory factors indicate the need. Intake and output records are maintained to determine the success of fluid resuscitation efforts.

A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client? A) Anemia B) Gastric ulcers C) Hyperthyroidism D) Cardiac arrest

Ans: B Feedback: The release of histamine as a consequence of the stress response increases gastric acidity. The client with a burn is prone to develop gastric ulcers. Anemia develops because of the heat destroying the erythrocytes. Release of histamine does not cause hyperthyroidism or cardiac arrest.

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) Removal of clothing B) Irrigation of the wound C) Application of ice D) Removal of hair

Ans: C Feedback: Application of ice causes vasoconstriction and diminishes needed blood flow to the zone of injury. Clothing and hair are removed from perimeter of burned area in an effort to remove course of bacterial contamination. Irrigation of the wound assists in the removal of debris.

A nurse is required to care for a client with facial burns who is prescribed the open method treatment. Which of the following nursing interventions should a nurse perform? A) Administer a cold sponge bath to the client. B) Keep the client's room cool and airy. C) Place a bed cradle or sheets over the client. D) Place the client on a moist linen sheet.

Ans: C Feedback:The skin of the client with burn is sensitive to drafts and temperature changes; therefore, a bed cradle or sheets should be placed over the client. The room should be kept warm and humidified, not cool and airy. The client should be placed in isolation in a bed with sterile, dry linen. Whirlpool baths are prescribed to loosen the crust, or eschar, which forms over the wound. Sponge baths are not advisable because particles from the sponge may cause accumulation of debris within the burn wound. Moist linen sheets are not placed on clients anymore due to their cooling effect, and they can lead the client to work hard to maintain proper body temperature.

During the recovery of an extensive burn, the client is complaining about wearing the tight-fitting custom garment. Which is the best response by the nurse? A) "Perhaps the garment should be resized." B) "The garment acts as a skin layer and prevents infection." C) "A snug fit is needed to minimize scarring and overgrowth of skin." D) "The garment can be removed for an hour each day."

Ans: C Feedback: The forming of burn scars can be minimized by the use of pressure dressings and custom-fitted garments that apply continuous pressure. Garments need to be snug in order to be effective. These garments are worn for 23 hours a day and may be prescribed for as long as 2 years. Prevention of infection is not indicated with use.

Which of the following are benefits that support the use of a closed method wound care in the management of a client with burns? Select all that apply. A) Provides a drier environment B) Promotes heat loss C) Creates antimicrobial barrier D) Prevents exudate accumulation E) Discourages hypertrophic scarring F) Promotes slower healing

Ans: C, E Feedback:The closed method is the preferred method of wound management for most burn victims. It creates a microbial barrier and applies direct pressure to the wound, which discourages hypertrophic scarring. Closed wound management provides a moist environment while reducing heat loss and evaporation, which facilitates faster healing. Frequent dressing changes may be required if the wound is infected or when there is significant exudate accumulation.

Following a serious thermal burn, which complication will the nurse take action to prevent first? A) Tissue hypoxia B) Infection C) Renal failure D) Hypovolemia

Ans: D Feedback: After a burn, fluid from the body moves toward the burned area, which leads to intravascular fluid deficit. Steps must be taken to prevent irreversible hypovolemic shock in the initial stages of treatment. The inflammatory processes that affect the tissues cause additional injury, which contributes to tissue hypoxia. Myoglobin and hemoglobin that were destroyed during the burn can result in acute renal failure. Destruction of the skin barrier results in colonization of bacteria and can lead to life-threatening infection in days following the burn.

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) 9% B) 18% C) 27% D) 36%

Ans: D Feedback:According to the rule of nines, the anterior portion of the lower extremity is 9% and the posterior portion of the lower extremity is 9%. Each lower extremity is therefore equal to 18%. Both lower extremities that have sustained burns to entire surfaces will equal to 36% of total surface area.

Which of the following skin substitutes is a nylon-silicone membrane coated with a protein derived from pig tissue? A) Mederma B) Integra C) TransCyte D) Biobrane

Ans: D Feedback:Biobrane is a nylon-silicone membrane coated with a protein derived from pig tissue. Mederma is a topical gel that can reduce scarring. Integra consists of a two-layer membrane: one is a synthetic epidermal layer, and the other contains cross-linked collagen fibers that mimic the dermal layer of skin. TransCyte is created by culturing human fibroblasts from the dermis with a biosynthetic semipermeable membrane attached to nylon mesh.

The nurse is providing education to the client with multiple burns and lists the options for skin grafting and application techniques. Which is the primary benefit for using an autograft slit graft versus other types of grafts? A) Less scarring B) Less discomfort C) Speeds healing D) Rejection is unlikely.

Ans: D Feedback:In an autograft slit graft, the skin is harvested from the client's buttocks or thighs. Rejection is less likely with this type of graft because the donor and recipient are the same. There will be scarring at both the donor and recipient sites, and added discomfort is associated from the donor site. Because the slit graft is expanded through a meshing device, the scarring will appear as a mesh. Healing is delayed due to need for two wounds.

Following a burn, the nurse understands that the focused management of which burn zone is of greatest concern? A) Zone in burn center B) Zone of coagulation C) Zone of hyperemia D) Zone of stasis

Ans: D Feedback: The zone of stasis lies outside the burn center and zone of coagulation. This is where the blood vessels are damaged, but tissue has the potential to survive with proper management. The center zone or zone of coagulation is the deepest area of injury and is considered the zone of irreversible damage, placing the focus on saving the surrounding tissues. The zone of hyperemia is the area of least injury.