Med Surg I Prep U Chapter 62: Management of Patients with Burn Injury, Med Surg I Prep U Chapter 61: Management of Patients with Dermatologic Disorders, PrepU Ch.60: Assessment of Integumentary Function, Med Surg I Prep U Chapter 16: End-of-Life Care...
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 nurse is performing a home visit to a patient who is recovering following a long course of inpatient treatment for burn injuries. When performing this home visit, the nurse should do which of the following?
Assess the patient's psychosocial state.
A patient in the emergent/resuscitative phase of a burn injury has had her lab work drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what?
Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis
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
A 6-year-old girl was playing near her family's campfire when she fell into the fire, suffering significant burns. She was taken by air ambulance to the burn unit where you practice nursing. What physiologic process furthers her burn injury?
Inflammatory
Which zone of burn injury sustains the most damage?
Inner
A patient with a burn wound is prescribed mafenide acetate 5% (Sulfamylon) twice daily. Nursing implications associated with this medication include which of the following?
Premedicating the patient with an analgesic prior to application
Which instruction is the most important to give a client who has recently had a skin graft?
Protect the graft from direct sunlight.
When caring for a client with burns, how often should a nurse change the wound dressing? Choose the correct option.
At least once a day
A nurse is teaching a patient with a partial-thickness wound how to wear his elastic pressure garment. How would the nurse instruct the patient to wear this garment?
Continuously
A patient experienced a 33% TBSA burn 72 hours ago. The nurse observes that the patient's hourly urine output has been steadily increasing over the past 24 hours. How should the nurse best respond to this finding?
Recognize that the patient is experiencing an expected onset of diuresis.
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
A patient is scheduled for an allograft to a burn wound. The patient asks what an allograft is. Which of the following information will the nurse include in the explanation?
"An allograft is a temporary wound covering obtained from cadaver skin."
A male patient, 16 years old, comes to the emergency department (ED) after burning his right hand and arm while working on a friend's car. The injury is determined to be a superficial burn and it is treated. What would the nurse teach the patient before discharging him home to return on a daily basis for dressing changes?
"The burned area will start to swell in about 4 hours and blisters will form. If you think the dressing is too tight come back to the ED."
A patient arrives in the emergency department after being burned in a house fire. The patient's burns cover the face and the left forearm. What extent of burns does the patient most likely have?
18%
The nurse is instructing a client using a pressure garment after a burn. For how long each day at a minimum will the nurse advise the client to wear the device? Fill in the blank with a number.
23
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%
Touring the burn unit of the trauma center where you just hired on as a nurse, the nurse manager discusses the decrease in number of burn cases per year. Nationally, how many people die of burn injuries each year?
3500
A client has experienced burns covering the back and front of both legs. Using the Rule of Nines, what percentage would the nurse assign to the client's injury when documenting? Fill in the blank with a number.
36
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 presents to the ED following a burn injury. The patient has burns to the anterior chest and entire left leg. Using the rule of nines, the nurse documents the total body surface area (TBSA) percentage as which of the following?
36%
Acticoat antimicrobial barrier dressings used in the treatment of burn wounds can be left in place for which timeframe?
5 days
A nurse has reported for a shift at a busy burns and plastics unit in a large university hospital. Which patient is most likely to have life-threatening complications?
A 4-year-old scald victim burned over 24% of the body
A patient 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 patient's needs?
A patient-controlled analgesia (PCA) system
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
The current phase of a patient's treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the patient is in what phase of burn care?
Acute
The nursing instructor is going over burn injuries. The instructor tells the students that the nursing care priorities for a patient with a burn injury include wound care, nutritional support, and prevention of complications such as infection. Based upon these care priorities, the instructor is most likely discussing a patient in what phase of burn care?
Acute
A nurse is caring for a patient 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
The nurse is caring for a patient 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
An emergency department nurse has just received a patient 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 patient's body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period?
Administer IV fluids
A patient is brought to the ED by paramedics who report the patient has partial-thickness burns on the chest and legs. The patient has also suffered smoke inhalation. What is a priority in the care of a patient who has been burned and suffered smoke inhalation?
Airway management
A patient is brought to the ED by paramedics, who report that the patient has partial-thickness burns on the chest and legs. The patient has also suffered smoke inhalation. What is the priority in the care of a patient who has been burned and suffered smoke inhalation?
Airway management
An autograft is harvested from a burn client under general anesthesia. Harvesting the client's own tissue has several disadvantages. Select all of the following that apply.
All answers are correct. • It compounds the client's pain because it creates a new wound. • The donor site has the potential for scarring and atypical pigment changes. • There is a potential for donor site infection. • There is a delay in wound closure while waiting for the donor site to heal and be reharvested.
A 42-year-old client suffered significant burns in a workplace accident. During his airlift to a regional burn unit, you assess his wounds taking care to find and mark his entrance and exit wounds. Which of the following conditions create the need for intensive care by specifically trained personnel?
All options are correct
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. Select the graft described as the following: a biologic source of skin similar to that of the client.
Allograft
Which of the following complications is common for victims of electrical burns?
Cardiac dysrhythmia
A nurse is caring for a patient during the acute phase of the burn. The nurse knows he is responsible for what?
Closely scrutinizing the burn wound to detect early signs of infection
Which of the following is a quick assessment technique to assess the percentage of burn injury? Choose the correct option.
Comparing the client's palm with the size of the burn wound
Which of the following actions is a quick assessment technique that the nurse might use to assess the percentage of a small or scattered burn injury?
Comparing the patient's palm with the size of the burn wound
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.
A patient 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 patient closely for what signs of the onset of burn shock?
Decreased blood pressure
When the ED nurse learns that a patient suffered a burn injury from a flash flame, the nurse anticipates which depth of burn?
Deep partial thickness
Tom Benson, a 42-year-old electrical lineman, suffered significant burns in a workplace accident. During his airlift to a regional burn unit, you assess his wounds taking care to find and mark his entrance and exit wounds. What occurrence makes it difficult to assess internal burn damage in electrical burns?
Deep tissue cooling
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 home safety
Within the burn unit, you must be continually aware that clients may develop potential complications based on the type of burn they endured. Which burns have a common complication of cardiac dysrhythmias?
Electrical
The nurse caring for a patient who is recovering from full-thickness burns is aware of the patient's risk for contracture and hypertrophic scarring. How can the nurse best mitigate this risk?
Encourage physical activity and range of motion exercises.
Molly Baker has a third-degree burn on her leg from a house fire. 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 her leg. What procedure would be done to relieve pressure on the affected area?
Escharotomy
Within the practice of nursing at the burn unit, there are specific potential complications common to specific types of burns. Which burns can impair ventilation?
Face, neck, chest
A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurse's immediate, priority concern when planning this patient's care?
Fluid status
A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. What would be the nurse's priority concern about this patient?
Fluid status
Bill Jenkins has suffered from a burn on his leg related to an engine fire. Burn depth is determined by assessing the color, characteristics of the skin, and sensation in the area. When the burn area was assessed, it was determined that he felt no pain in the area and that it appeared charred. What depth of burn injury would he be said to have?
Full thickness (third degree)
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
A patient is brought to the Emergency Department from the site of a chemical fire. The paramedics report that the patient has a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. When you assess the patient he verbalizes no pain in the right arm and the skin appears charred. Based upon these assessment findings, what is the depth of the burn on the patient's right arm?
Full-thickness
A patient is brought to the emergency department from the site of a chemical fire, where he suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the patient's arm?
Full-thickness
Which type of burn injury requires skin grafting?
Full-thickness
A 57-year-old firefighter was severely burned fighting a house fire. During his aggressive treatment, the client begins to exhibit symptoms of renal failure. What physiologic process can cause acute renal failure?
Hemoconcentration
A patient is admitted to the burn unit after being transported from a facility 1000 miles away. The patient has burns to the groin area and circumferential burns to both upper thighs. When assessing the patient's legs distal to the wound site, the nurse should be cognizant of the risk of what complication?
Ischemia
A patient'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 of the following is the preferred IV fluid for burn resuscitation?
Lactated Ringer's (LR)
A client has partial-thickness burns on both lower extremities and portions of the trunk. Which I.V. fluid does the nurse plan to administer first?
Lactated Ringer's solution
In a client who has been burned, which medication should the nurse expect to use to prevent infection?
Mafenide (Sulfamylon)
The patient you are caring for has an electrical burn and has developed thick eschar over the burn wound. Which of the following topical antibacterial agents will the nurse expect the physician to order for the wound?
Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream
Which type of debridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar?
Mechanical debridement
Which of the following is the analgesic of choice for burn pain?
Morphine sulfate
The nurse is caring for a patient with deep partial-thickness burn injuries. Which of the following statements reflect 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 in the burn unit. Which of the following may be an early sign of sepsis in the patient with burn injury?
Narrowing pulse pressure
What is a priority in the rehabilitation phase of the burn injury?
Patient and family education
A home care nurse is performing a visit to a patient's home to perform wound care following the patient's hospital treatment for severe burns. While interacting with the patient, the nurse should assess for evidence of what complication?
Post-traumatic stress disorder
The nurse is preparing the patient for mechanical débridement and informs the patient that this will involve which of the following procedures?
Removal of eschar until the point of pain and bleeding occurs
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.
Eric Gardner, a 25-year-old groundskeeper, was burned in a home accident, and is being seen in the ED where you practice nursing. The physician classified his wound, completed treatment and recommended he see his primary care physician for follow-up care. The ED physician indicated his wounds, with proper care, should heal within 2 weeks. What would you expect Mr. Gardner's would to be classified?
Second degree
A nurse is caring for a patient in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values?
Sodium deficit
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
All of the following are antimicrobials commonly used to treat burns except:
Tetracycline
An emergency department nurse learns from the paramedics that they are transporting a patient 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
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
It is time to change the dressings on a burn patient. What does the nurse do to reduce pain and discomfort at this time?
The nurse changes dressings as quickly as possible.
While performing a patient's ordered wound care for the treatment of a burn, the patient has made a series of sarcastic remarks to the nurse and criticized her technique. How should the nurse best interpret this patient's behavior?
The patient may be experiencing anger about his circumstances that he is deflecting toward the nurse.
An emergency department nurse has just admitted a patient with a burn. What characteristic of the burn will primarily determine whether the patient experiences a systemic response to this injury?
The total body surface area (TBSA) affected by the burn
The nurse is caring for a patient with superficial partial-thickness burn injuries to the lower extremities. The patient is ordered IV morphine for pain. The nurse understands narcotics are given IV to manage pain during the initial management of pain because of which of the following?
Tissue edema may interfere with drug absorption via other routes.
A nurse is developing a care plan for a patient 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
The nursing students are doing clinical hours on the burn unit. A nurse is developing a care plan for a patient with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. A nursing student asks why this goal is important when the patient is fighting for his life. What should the burn nurse respond?
To prevent contractures
What is the nursing goal during the acute phase of a burn?
To ultimately prevent or control infection in the burn population
A patient with a partial-thickness burn injury had Biobrane applied 2 weeks ago. The nurse notices that the Biobrane is separating from the burn wound. What is the appropriate nursing intervention when this separation occurs?
Trim away the separated Biobrane.
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
A client has a skin graft and is also using a pressure garment as part of the recovery following a burn injury. Which of the following measures would the nurse advise the client to follow?
Use a sunscreen with a high SPF while outdoors to protect against pigment changes.
Which of the following is an early sign of sepsis in the burn injured patient?
Widened pulse pressure
Which of the following is a quick assessment technique to assess the percentage of burn injury?
Within the burn unit, you must be continually aware that clients may develop potential complications based upon the type of burn they endured. Which burns have a common complication of cardiac dysrhythmias?
During the acute phase of a burn, a nurse should assess:
circulatory status.
The most important intervention in the nutritional support of a patient with a burn injury is to provide adequate nutrition and calories to
decrease catabolism.
A client with deep partial-thickness and full-thickness burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse provides additional client teaching because these exercises may:
dislodge the autografts.
A nurse is developing a care plan for a client recovering from a serious thermal burn. After maintaining respirations, the nurse knows that the most important immediate goal of therapy is:
maintaining the client's fluid, electrolyte, and acid-base balance.
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 is being cared for in a burn unit after suffering partial-thickness burns. The patient's laboratory work reveals a positive wound culture for gram-negative bacteria. The health care provider orders silver sulfadiazine (Silvadene) to be applied to the patient's burns. The nurse provides information to the patient about the medication. Which of the following statements made by the patient 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 client is being discharged from the burn unit after having skin grafting done. He is being instructed in the use of a pressure garment. Select all of the following that are the client should be told.
• All are correct. • Wear the pressure garment at least 23 hours a day. • Follow the manufacturer's instructions for donning and removing the pressure garment.
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? Choose all that apply.
• Place the client in a horizontal position. • Roll the client in a blanket to smother the fire.
A patient is in the acute phase of a burn injury. One of the nursing diagnoses in the plan of care is Ineffective Coping Related to Trauma of Burn Injury. What interventions appropriately address this diagnosis? Select all that apply.
• Promote truthful communication. • Teach the patient coping strategies. • Provide positive reinforcement.
Which of the following instructions should a nurse provide a client with burns who has undergone a skin grafting? Choose all correct options.
• Restrict movement for a period of time • Wear a pressure garment for up to two years
Which of the following are possible indicators of pulmonary damage from an inhalation injury? Select all that apply.
• Singed nasal hair • Hoarseness • Facial burns
