Module 21A-Burns
13) An adult burn patient is receiving fluid resuscitation of warm, lactated Ringer's solution during the first 24 hours following injury. The client's hourly urine output is being monitored to determine whether the resuscitation is adequate. The most recent reading is 1.10 mL/kg/hr. The nurse understands that this amount of urine output is A) slightly higher than the normal range. B) slightly lower than the normal range. C) within the normal range. D) extremely low.
Answer: A Explanation: A) In adult patients with burn injuries who are receiving fluid resuscitation, urine production of 0.5-1 mL/kg/hr is considered normal. Therefore, the nurse would understand that this patient's output is slightly high.
7) The nurse is planning care for a client in the acute stage of a burn injury. Which aspects of care should the nurse identify as a priority? Select all that apply. A) Nutrition B) Psychosocial support C) Pain management D) Fluid resuscitation E) Wound care
Answer: A, C, E Explanation: A) Nursing care for the client during the acute stage of burn injuries will include wound care, nutritional therapy, and pain management. Fluid resuscitation occurs during the emergency phase of burn care. Psychosocial support will be needed once the client has stabilized.
1) The nurse is providing care to a pediatric client who was admitted to the pediatric intensive care unit (PICU) with a partial-thickness thermal burn. When planning care for this client, which should the nurse consider regarding this type of burn? A) Partial-thickness burns are deeper than superficial burns but still involve the epidermis only. B) A superficial partial-thickness burn extends from the skin's surface into the papillary layer of the dermis. C) A deep partial-thickness burn is often bright red and has a moist, glistening appearance with blister formation. D) A superficial partial-thickness burn is less painful than a deep partial-thickness burn.
Answer: B Explanation: A) A superficial partial-thickness burn extends from the skin's surface into the papillary layer of the dermis. Partial-thickness burns are deeper than superficial burns, extending from the epidermis into the dermis layer as well. A superficial partial-thickness burn is often bright red and has a moist, glistening appearance with blister formation. A deep partial-thickness burn is less painful than a superficial partial-thickness burn because sensation is decreased at the site.
6) A client who sustained burns to both lower extremities reports feeling frustrated by not being able to provide self-care. Which nursing diagnosis would be appropriate for the client at this time? A) Ineffective Coping B) Powerlessness C) Anxiety D) Situational Low Self-Esteem
Answer: B Explanation: A) The client is expressing frustration over not being able to provide self-care. The nursing diagnosis most appropriate for the client at this time would be Powerlessness. There is not enough information to determine whether the client is or is not experiencing situational low self-esteem, ineffective coping, or anxiety.
5) An older adult client with severe burns over more than half of the body has an indwelling catheter. When evaluating the client's intake and output, which of the following should be taken into consideration? A) The amount of urine will be elevated due to the amount of intravenous fluids administered during the initial phases of treatment. B) The amount of urine will be reduced in the first 24 to 48 hours and will then increase. C) The amount of urine will be reduced during the first 8 hours of the burn injury and will then increase as diuresis begins. D) The amount of urine output will be greatest in the first 24 hours after the burn injury.
Answer: B Explanation: A) The client will have an initial reduction in urinary output. Fluid is reduced in the initial phases as the body manages the insult caused by the injury and fluids are drawn into the interstitial spaces. After the shock period passes, the client will enter a period of diuresis. Diuresis begins between 24 and 36 hours after the burn injury.
11) The nurse is planning to provide care to extended family members spanning three generations who are being treated for burn injuries after a fire. Based on an understanding of lifespan factors, the nurse should anticipate that which of the following is true? A) The 38-year-old pregnant mother is more likely to require an allograft than the other members of the family. B) The 82-year-old grandmother is more likely to have burns to a greater percentage of her total body surface area (TBSA) than younger family members. C) The 14-year-old son is less likely to experience edema associated with his injuries than older members of the family. D) The 6-year-old daughter is more likely to go into burn shock than the other members of the family.
Answer: B Explanation: A) The older adult population is more likely to suffer burns to a greater percentage of their TBSA than other age groups, largely because their skin is so much thinner and therefore more delicate than that of younger individuals. The other assumptions cannot be made based on patient age alone and depend on the depth and extent of the burns, which is information that is unavailable at this time.
2) A nurse working at a burn center is caring for a client with an electrical burn. According to the American Burn Association, how would this burn be classified? A) Minor B) Moderate C) Major D) Significant
Answer: C Explanation: A) According to the American Burn Association, all electrical burns are classified as major. Significant is not a classification according to the American Burn Association, and all other choices are incorrect.
14) A burn patient is currently in the acute stage. When did this stage begin, and when will it end? A) It began with the onset of the burn injury and will end with fluid resuscitation. B) It began with wound closure and will end when the patient's health is fully restored. C) It began with the start of diuresis and will end with the closure of the burn wound. D) It began with the onset of the burn injury and will end with the closure of the burn wound.
Answer: C Explanation: A) The acute stage begins with the start of diuresis and ends with the closure of the burn wound, either by natural healing or by use of skin grafts. The emergent/resuscitative stage begins with the onset of the burn injury and ends with successful fluid resuscitation. The rehabilitative stage begins with wound closure and ends when the patient returns to the highest level of health restoration, which may take years.
9) The nurse is caring for a client who is to receive mechanical debridement of burn wounds. Which methods should the nurse anticipate using to complete this treatment? Select all that apply. A) Homograft B) Application of a topical agent to dissolve necrotic tissue C) Irrigation of the burn wounds D) Application of wet-to-dry gauze dressings E) Hydrotherapy
Answer: C, D, E Explanation: A) Mechanical debridement is done by applying and removing wet-to-dry gauze dressings, using hydrotherapy, or using irrigation. Applying a topical agent to dissolve necrotic tissue is an example of enzymatic debridement. The application of a homograft is a type of dressing and not a type of debridement.
4) Which data supports the nurse's concern that a client is at a high risk for a burn injury? Select all that apply. A) Part-time employment at a convenience store B) Diagnosis of hypertension C) Age 71 years D) Uses public transportation for grocery shopping E) Currently smokes one pack of cigarettes per day
Answer: C, E Explanation: A) Older clients are more vulnerable to fire and burn injury because of decreased visual acuity, depth perception, senses of smell and hearing, and because of impaired mobility. Alterations in cognition, such as dementia, are also risk factors. Smoking is another risk factor. All of these factors increase the risk of accidentally starting a fire and diminish the ability to survive it. Hypertension does not increase the client's risk for experiencing a burn injury. Part-time employment and use of public transportation do not increase the client's risk of experiencing a burn injury.
8) The nurse is evaluating the adequacy of the burn-injured client's nutritional intake. Which laboratory value is the best indicator of nutritional status? A) Creatine phosphokinase (CPK) B) Blood urea nitrogen (BUN) levels C) Hemoglobin D) Albumin level
Answer: D Explanation: A) Albumin level is used to indicate protein synthesis and nutritional status. Creatine phosphokinase is used to identify the presence of muscle injuries. BUN levels are used to evaluate kidney function. Hemoglobin levels will fluctuate with the stages of the burn injury, dependent on the fluid status.
3) A client is evaluated after suffering severe burns to the torso and upper extremities. The nurse notes edema at the burned areas. Which of the following best describes the underlying cause of this manifestation? A) Decreased osmotic pressure in the burned tissue B) Reduced microvascular permeability at the site of the burned area C) Increased potassium in the intracellular compartment D) Inability of the damaged capillaries to maintain fluids in the cell walls
Answer: D Explanation: A) Burn shock occurs during the first 24-36 hours after the injury. During this period, there is a shifting of fluid volume that is the direct result of lost cell wall integrity at the injury site and in the capillary bed. There is an increase in microvascular permeability at the burn site. The osmotic pressure is also increased, causing fluid accumulation. Potassium ions leave the intracellular compartment, putting patients at risk for cardiac dysrhythmia due to hypokalemia.
12) An adult burn patient is brought in to the intensive care unit (ICU) for treatment. Prior to sustaining the injury, the client was considered underweight for her height. The nurse understands that this may have important implications for the client because A) she will have lower fluid resuscitation calculations than patients of normal weight. B) she will be at greater risk for developing cardiac or renal insufficiencies. C) she will require more supportive care than patients who are normal weight. D) she will lose as much as 20% of her preburn weight during rehabilitation.
Answer: D Explanation: A) During the acute and rehabilitative phases of the burn injury, the patient loses as much as 20% of preburn weight. This has significant implications for all patients, especially those who are underweight at the time of injury. Fluid resuscitation calculations are based on the time of injury, not body weight. Patients with a past medical history of cardiac or renal problems are at an increased risk for cardiac and renal insufficiency regardless of weight. Children and older adults require more supportive care than other client populations because of differences in their skin and healing, not because of their body weight
10) How should the nurse position a client who is returned to the burn unit following a graft procedure to the leg? A) Place the client flat with the affected extremity abducted. B) Elevate the head of bed 30 degrees C) Maintain the head of bed flat D) Elevate the affected extremity
Answer: D Explanation: A) Elevating the affected extremity will reduce edema and promote perfusion. Elevating the head of bed, leaving the head of bed flat, and abducting the extremity will not increase healing or improve the client's long-range prognosis.
