S4 N243 PrepU - Ch. 62: Management of Patients with Burn Injury

20. When using the Palmer method to estimate the extent of the burn injury, the nurse determines the palm is equal to which percentage of total body surface area? 2 1 4 3

1 Explanation: In clients with scattered burns, or for a quick prehospital assessment, the Palmer method may be used to estimate the extent of the burns. The size of the client's palm, including the surface area of the digits, is approximately 1% of the total body surface area.

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

"A snug fit is needed to minimize scarring and to smooth the skin." Explanation: 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.

1. 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% 36%

27% Explanation: According to the Rule of Nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the client received burns to his back (18%) and one arm (9%), totaling 27% of his body.

13. 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? 36% 18% 27% 9%

27% Explanation: According to the Rule of Nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the client received burns to his back (18%) and one arm (9%), totaling 27% of his body.

13. A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned? 36% 27% 45% 18%

27% Explanation: The TBSA would be 27%. That is 18% of the body surface for the anterior trunk and 9% for the left arm.

The nurse is preparing to initiate fluid resuscitation for a patient weighing 130 pounds (59 kg) who suffered a 58% total body surface area (TBSA) thermal burn. The health care provider ordered: 2 mL lactated Ringer's (LR) × patient's weight in kilograms × %TBSA to be administered over 24 hours. The nurse will administer ________________________ mL of fluid over the first 8 hours post-burn injury? ________

3422 Explanation: Convert pounds. to kilograms = 130/2.2 = 59 kg 2 mL x 59 kg x 58% TBSA = 6844 mL/24 hr. The infusion is regulated so that one-half of the calculated volume is administered in the first 8 hours after burn injury, so the nurse would infuse 3422 in the first eight hours and the second half of the calculated volume over the next 16 hours. Fluid resuscitation formulas are only a guideline. It is imperative that the rate of infusion be titrated hourly as indicated by physiologic monitoring of the patient's response.

10. A client with a burn over the lower leg asks why surgery is planned to remove the dead burned tissue. Which response will the nurse make? "it encourages your body's natural processes to liquefy any damaged tissue." "It reduces the amount of scarring that will occur on the skin." "It reduces the amount of wound care that you will need as the skin heals." "It reduces the risk of complications from an infection."

"It reduces the risk of complications from an infection." Explanation: Early surgical excision to remove devitalized tissue along with early burn wound closure has long been recognized as one of the most important factors contributing to survival in a client with a major burn injury. When conducted in a timely and efficient manner, surgical excision results in shorter lengths of hospital stay and decreased risk of complications from invasive burn wound sepsis. Surgical debridement is not done to reduce the amount of scarring or the amount of wound care that will be needed. Natural debridement is a bodily process that liquefies any damaged tissue and may take weeks to months to occur.

1. 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 urinary output of 30 mL/hr Explanation: For adults, a urine output of 30 to 50 mL per hour is used as an indication of appropriate resuscitation in thermal and chemical injuries, whereas in electrical injuries a urine output of 75 to 100 mL per hour is the goal (ABA, 2011a).

9. Which of the following measures can be used to cool a burn? Wrapping the person in ice Application of ice directly to burn Application of cool water Using cold soaks or dressings for at least 1 hour

Application of cool water Explanation: Once a burn has been sustained, the application of cool water is the best first-aid measure. Never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns.

6. During the late stages of healing, which intervention helps a burn wound to heal with minimal scarring? Wearing clothing to protect the burn from the sun Removing eschar from the skin Maintaining wound care irrigation Applying continuous-compression wraps

Applying continuous-compression wraps Explanation: Applying continuous-compression wraps helps skin healing and prevents hypertrophied tissue from forming. Removing eschar from the skin, wearing clothing to protect the burn from the sun, and maintaining wound care irrigation are appropriate for the client with a burn wound, but these interventions don't necessarily help minimize scarring.

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

Applying knee splints Explanation: Applying knee splints is one method which can help prevent leg contractures by holding the joints in a position of function. Elevating the foot of the bed can't prevent contractures because this action doesn't hold the joints in a position of function. Hyperextending a body part for an extended time is inappropriate because it can cause contractures. Performing shoulder range-of-motion exercises can prevent contractures in the shoulders, but not in the legs which is the focus for this individual's treatment and care.

5. Which of the following skin substitutes is a nylon-silicone membrane coated with a protein? Biobrane Transcyte Mederma Integra

Biobrane Explanation: Biobrane is a nylon-silicone membrane coated with a protein. 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.

6. Which of the following is a disadvantage of surgical debridement? Scarring Bleeding Loss of function Contractures

Bleeding Explanation: A disadvantage of surgical debridement is bleeding. Scarring, loss of function, and contractures are not disadvantages of surgical debridement.

6. Burn shock is characterized by which of the following? Organ hyperperfusion Elevated blood pressure (BP) Capillary leak Severe hypervolemia

Capillary leak Explanation: Burn shock is characterized by capillary leak, "third spacing" of fluid, severe hypovolemia, and decreased cardiac output (CO). Progressive edema develops in unburned tissue and organs, causing hypoperfusion and hypovolemic shock. As fluid loss continues and vascular volume decreases, the CO and BP falls. This is the onset of burn shock.

9. Which complication is common for victims of electrical burns? Infection Cardiac dysrhythmia Inhalation injury Hypovolemic shock

Cardiac dysrhythmia Explanation: Cardiac dysrhythmias are common for victims of electrical burns. If the patient has an electrical burn, a baseline electrocardiogram (ECG) is obtained and continuous monitoring is initiated. Any burn injury can lead to complications, such as inhalation injury, infection, and hypovolemic shock.

5. Which zone consists of the area where the injury is most severe and deepest? Stasis Necrosis Coagulation Hyperemia

Coagulation Explanation: 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.

20. What quick assessment technique should the nurse use to assess the percentage of burn injury? Compare the client's palm with the size of the burn wound Observe the color of the client's wound Observe the client's level of consciousness Check the client's vital signs

Compare the client's palm with the size of the burn wound Explanation: A quick technique to assess the percentage of burn injury is to compare the client's palm with the size of the burn wound. The palm is approximately 1% of a person's total body surface area. Observing the color of the client's wound, checking the client's vital signs, and observing the client's level of consciousness determine the client's health status but do not help assess the percentage of burn injury.

10. 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. Blistered with a mottled red base. Reddened; blanches with pressure. Broken epidermis that is weeping.

Dry and pale white. Explanation: The wound appearance for a full-thickness burn would be dry, pale white, leathery, or charred.

6. 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. Epidermal layer only. Dermis and connective tissue. Entire dermis and subcutaneous tissue.

Epidermis and a portion of deeper dermis. Explanation: A deep partial-thickness burn includes the epidermis, upper dermis, and a portion of the deeper dermis. A burn limited to the epidermal layer is classified as a superficial partial-thickness burn. The last two choices refer to a full-thickness burn.

1. 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? Administer pain medication. Establish a patent airway. Replace fluids. Insert an indwelling catheter.

Establish a patent airway. Explanation: Nursing assessment in the emergent phase of burn injury focuses on the major priorities for any trauma patient; the burn wound is a secondary consideration to stabilization of airway, breathing, and circulation.

4. A client is brought to the ED with burns exceeding 20% of total body surface area. Which is the primary nursing intervention in the care of this client Prevent infection Fluid resuscitation Strict intake and output Endotracheal tube placement

Fluid resuscitation Explanation: 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.

16. Which type of burn injury requires skin grafting? Full-thickness Superficial partial-thickness Superficial Deep partial-thickness

Full-thickness Explanation: A full-thickness burn injury heals by contraction or epithelial migration and requires grafting. The other types of burn injury do not require skin grafting.

20. 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? Deep partial-thickness Superficial Superficial partial-thickness Full-thickness

Full-thickness Explanation: A full-thickness burn involves total destruction of the dermis and extends into the subcutaneous fat. It can also involve muscle and bone. A superficial burn only damages the epidermis. In a superficial partial-thickness burn, the epidermis is destroyed and a small portion of the underlying dermis is injured. A deep partial-thickness burn extends into the reticular layer of the dermis and is hard to distinguish from a full-thickness burn. It is red or white, mottled, and can be moist or fairly dry.

7. Skin grafts are necessary for what type of burn? Superficial Full-thickness Superficial partial thickness First degree

Full-thickness Explanation: 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.

10. When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately? Urine output of 70 ml the first hour Complaints of intense thirst Moderate to severe pain Hoarseness of the voice

Hoarseness of the voice Explanation: Hoarseness is indicative of injury to the respiratory system and could indicate the need for immediate intubation. Thirst following burns is expected because of the massive fluid shifts and resultant loss, leading to dehydration. Pain, either severe or moderate, is expected with a burn injury. The client's urine output is adequate.

7. 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? Xenografts Heterografts Autografts Homografts

Homografts Explanation: Homografts (or allografts) and xenografts (or heterografts) are also referred to as biologic dressings and are intended to be temporary wound coverage. Homografts are skin obtained from recently deceased or living humans other than the patient. Xenografts consist of skin taken from animals (usually pigs). An autograft uses the client's own skin, which is transplanted from one part of the body to another.

2. The nurse recognizes that which of the following provide clues about fluid volume status? Select all that apply. Percentage of meals eaten Skin turgor Hourly urine output Daily weights Oxygen saturation

Hourly urine output Daily weights Skin turgor Explanation: Monitoring of hourly urine output and daily weights provides clues about fluid volume status. Skin turgor is a sign of fluid loss (dehydration). Percentage of meals eaten, and oxygen saturation would not be reliable indicators of fluid volume status in the client.

4. A child tips a pot of boiling water onto his bare legs. The mother should: Immerse the child's legs in cool water. Cover the child's legs with ice cubes secured with a towel. Liberally apply butter or shortening to the burned areas. Avoid touching the burned skin and take the child to the nearest emergency department.

Immerse the child's legs in cool water. Explanation: The application of cool water is the best first-aid measure. Soaking the burned area intermittently in cool water or applying cool towels gives immediate and striking relief from pain and limits local tissue edema and damage.

8. Which zone of burn injury sustains the most damage? Outer Middle Inner Protective

Inner Explanation: Each burned area has three zones of injury. The inner area (known as the zone of coagulation, where cellular death occurs) sustains the most damage. The middle area, or zone of stasis, has a compromised blood supply, inflammation, and tissue injury. The outer zone, the zone of hyperemia, sustains the least damage.

10. A young child is being evaluated for an 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? Lund and Browder method Rule of nines Parkland formula method Hand method

Lund and Browder method Explanation: The Lund and Browder method divides the 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.

4. 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? Sit in a chair, elevate his legs, and have someone cut his pants off around the burned area. Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel. Lie down, have someone cover him with a blanket, and cover his legs with petroleum jelly. Remove his burned pants so that the air can help cool the wound.

Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel. Explanation: After the flames are extinguished, the burned area and adherent clothing are soaked with cool water, briefly, to cool the wound and halt the burning process.

7. A client brought to the emergency department has been exposed to smoke and flames from a house fire. What assessment finding is most important to the nurse in determining care of the client? Elevation of blood pressure and heart rate Fracture of the fibula with displacement Presence of soot around nasal passages Partial-thickness burns to hands and wrists

Presence of soot around nasal passages Explanation: 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.

2. Following a burn injury, the nurse determines which area is the priority for nursing assessment? Nutrition Pulmonary system Cardiovascular system Pain

Pulmonary system Explanation: Airway patency and breathing must be assessed during the initial minutes of emergency care. Immediate therapy is directed toward establishing an airway and administering humidified 100% oxygen. Pulmonary problems may be caused by the inhalation of heat and/or smoke or edema of the airway. Assessing a patent airway is always a priority after a burn injury followed by breathing. Remember the ABCs.

3. Which of the following fluid or electrolyte changes occur in the emergent/resuscitative phase? Potassium deficit Increased urinary output Reduction in blood volume Sodium excess

Reduction in blood volume Explanation: A reduction in blood volume occurs secondary to plasma loss. Sodium deficit, potassium excess, and decreased urinary output occurs in this phase.

18. A nurse is aware that after a burn injury and respiratory difficulties have been managed, the next most urgent need is to: Monitor cardiac status. Replace lost fluids and electrolytes. Measure hourly urinary output. Prevent renal shutdown.

Replace lost fluids and electrolytes. Explanation: After managing respiratory difficulties, the next most urgent need is to prevent irreversible shock by replacing lost fluids and electrolytes. The total volume and rate of IV fluid replacement are gauged by the patient's response and guided by the resuscitation formula.

8. 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? Infection Risk Altered Tissue Perfusion Acute Pain Risk for Impaired Gas Exchange

Risk for Impaired Gas Exchange Explanation: 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.

16. Which intervention helps to minimize the risk of further injury to an affected person at the scene of a fire? Cover the client with a wet cloth Avoid immediate IV fluid therapy Roll the client in a blanket Place the client with the head positioned slightly below the rest of the body

Roll the client in a blanket Explanation: At the scene of a fire, the client should be rolled in a blanket to smother the fire. The client should be placed in a horizontal position to prevent the fire, hot air, and smoke from rising toward the head and entering the respiratory passage. The client should not be covered immediately with a wet cloth or kept in any position other than horizontal. However, IV fluid therapy should be administered en route to the hospital.

19. Which of the following are possible indicators of pulmonary damage from an inhalation injury? Select all that apply. Singed nasal hair Yellow sputum Hoarseness Bradypnea Facial burns

Singed nasal hair Hoarseness Facial burns Explanation: Indicators of possible pulmonary damage include singed nasal hair, hoarseness, voice change, stridor, burns of the face or neck, sooty or bloody sputum, and tachypnea.

1. A nurse is preparing a care plan for a client burned over 36% of his body 2 days ago. 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. Explanation: During the intermediate phase of burn care, the client's hematocrit should diminish as a result of hemodilution, which occurs as the fluids shift back into the circulating blood volume from the tissues. In the intermediate phase of burn care, the client will experience serum sodium deficits. Urinary output increases during this phase as renal perfusion increases. Loss of serum sodium leads to metabolic acidosis, not metabolic alkalosis.

12. 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 is alert and conscious. The client's breathing is unlabored, and skin is clammy. The client's heart rate is rapid and regular. The client's urinary output is 0.5 to 1 mL/kg/hour.

The client's urinary output is 0.5 to 1 mL/kg/hour. Explanation: Successful fluid resuscitation is gauged by a urinary output of 0.5 to 1 mL/kg/hour via an indwelling catheter. Fluid resuscitation does not directly affect the client's heart rate, breathing, or mental status.

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

To keep fire and smoke from airway Explanation: 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. The stop, drop, and roll method is a quick and efficient means to extinguish flames. If hypovolemic shock occurs, lowering the head will assist in promoting blood flow to the head.

9. 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? Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg White pulmonary secretions Rectal temperature of 100.4° F (38° C) Urine output of 20 ml/hour

Urine output of 20 ml/hour Explanation: A urine output of less than 30 ml/hour in a client with burns indicates a deficient fluid volume. This client's PaO2 value falls within the normal range (80 to 100 mm Hg). White pulmonary secretions are normal. The client's rectal temperature isn't significantly elevated, and the slight increase in temperature probably results from the deficient fluid volume.

18. The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to increase metabolic rate. increase skeletal muscle breakdown. increase glucose demands. decrease catabolism.

decrease catabolism. Explanation: The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to decrease catabolism. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50%. A marked increase in metabolic rate is seen after a burn injury and interventions are instituted to decrease metabolic rate and catabolism. A marked increase in glucose demand is seen after a burn injury and interventions are instituted to decrease glucose demands and catabolism. Rapid skeletal muscle breakdown with amino acids serving as the energy source is seen after a burn injury and interventions are instituted to decrease catabolism.

15. 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: infection. pain management. body image. fluid resuscitation.

pain management. Explanation: With a superficial partial-thickness burn such as a solar burn, the nurse's main concern is pain management. Fluid resuscitation and infection become concerns if the burn extends to the dermal and subcutaneous skin layers. Body image disturbance is a concern that has lower priority than pain management.

4. 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: fluid resuscitation. pain management. infection. body image.

pain management. Explanation: With a superficial partial-thickness burn such as a solar burn, the nurse's main concern is pain management. Fluid resuscitation and infection become concerns if the burn extends to the dermal and subcutaneous skin layers. Body image disturbance is a concern that has lower priority than pain management.

7. A client with a burn wound is prescribed mafenide acetate 5% twice daily. Nursing implications associated with this medication include protecting the bed linens and client's clothing from contact to prevent staining. monitoring the client's Na+ and K+ serum levels and replace as prescribed. monitoring the client for the development of respiratory acidosis. premedicating the client with an analgesic prior to application.

premedicating the client with an analgesic prior to application. Explanation: Mafenide is a strong carbonic anhydrase inhibitor and may cause metabolic acidosis. Application may cause considerable pain initially, thus premedicating the client is an appropriate intervention. The other nursing implications are not associated with mafenide.

20. Which antimicrobials is not commonly used to treat burns? mafenide (Sulfamylon) tetracycline silver nitrate (AgNO3) 0.5% solution silver sulfadiazine (Silvadene)

tetracycline Explanation: Silver sulfadiazine (Silvadene), mafenide (Sulfamylon), and silver nitrate (AgNO3) 0.5% solution are the three major antimicrobials used to treat burns.

8. Which of the following is the analgesic of choice for burn pain? Tylenol with codeine Fentanyl Morphine sulfate Demerol

Morphine sulfate Explanation: Morphine sulfate remains the analgesic of choice. It is titrated to obtain pain relief on the patient's self-report of pain. Fentanyl is particularly useful for procedural pain, because it has a rapid onset, high potency, and short duration, all of which make it effective for use with procedures. Demerol and Tylenol with codeine are not analgesics of choice for burn pain.

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

Myoglobin in the urine Explanation: 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.

1. A client with superficial burns on the face and deep partial-thickness burns on the neck and chest is undergoing treatment and is anxious to know about skin grafting. For which of the following areas can skin grafting be suggested? Neck and chest Face, neck, and chest Face and neck Face only

Neck and chest Explanation: Skin grafting is essential for deep partial-thickness burns on the client's neck and chest because the skin layers responsible for regeneration have been destroyed. The client's face does not need skin grafting because the burns are superficial and will heal unassisted.

16. 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? Diverticulitis Ulcerative colitis Paralytic ileus Hematemesis

Paralytic ileus Explanation: Patients who are critically ill, including those with burns, are predisposed to altered gastrointestinal (GI) motility for many reasons, which may include impaired enteric nerve and smooth muscle function, inflammation, surgery, medications, and impaired tissue perfusion. Three of the most common GI alterations in burn-injured patients are paralytic ileus (absence of intestinal peristalsis), Curling's ulcer, and translocation of bacteria. Decreased peristalsis and bowel sounds are manifestations of paralytic ileus.

13. 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. Place the client in a vertical position. Open a door and encourage air in an enclosed space.

Place the client in a horizontal position. Roll the client in a blanket to smother the fire. Explanation: If the clothing is on fire, the client is placed in a horizontal position and rolled in a blanket to smother the fire.

17. 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? Weight Age Family history Preexisting conditions

Preexisting conditions Explanation: 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.

16. 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." "An allograft is an expensive sheet of skin obtained from a culture." "An allograft is a permanent wound covering taken from a donor site in your body." "An allograft is a temporary wound covering obtained from pig skin."

"An allograft is a temporary wound covering obtained from cadaver skin." Explanation: There are several different temporary and permanent coverings for burn wounds. Homografts (or allografts) and xenografts (or heterografts) are also referred to as biologic dressings and are intended to be temporary wound coverage. Homografts are skin obtained from recently deceased or living humans other than the client. Xenografts consist of skin taken from animals (usually pigs). Therefore, the body's immune response will eventually reject them as a foreign substance.

14. 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?" "Are any of the victims expected to have electrical burns?" "How many victims are anticipated for transport?" "Are the victims suffering from thermal burns?"

"Are the burns associated with chemicals used in the plant?" Explanation: 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.

19. The nurse has completed teaching home care instructions to a client being discharged from the burn unit. Which statement from the client indicates the need for further teaching? "I can work with the social worker to find funding assistance programs to help with my medical expenses." "I will drink a lot of fluids to prevent constipation since I am taking pain medications." "I will wear sun block with the highest SPF possible to protect exposed burned skin from the sun." "As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help."

"As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help." Explanation: Itching is a normal part of healing. Many clients describe this as one of the most uncomfortable aspects of burn recovery. The client can apply mild moisturizers to decrease itching from dryness. Medications can be discussed with your treatment team. The client should pat the areas; scratching is contraindicated. The other statements indicate that teaching has been effective.

4. To meet early nutritional demands for protein, a 198-lb (90-kg) burned patient will need to ingest a minimum of how much protein every 24 hours? 270 g/day 180 g/day 110 g/day 90 g/day

180 g/day Explanation: Recommendations from recent literature advocate protein requirements of 1.5 to 2 g/kg/day (Saffle, Graves, & Cochran, 2012).

13. A client has undergone grafting following a burn injury. The nurse understands that the first dressing change at the site of an autograft is performed how soon after the surgery? Within 12 hours after surgery As soon as sanguineous drainage is noted 2 to 5 days after surgery Within 24 hours after surgery

2 to 5 days after surgery Explanation: The first dressing change usually occurs 2 to 5 days after surgery. In addition, a foul odor or purulence may indicate infection and should be reported to the surgeon immediately. Sanguineous drainage on a dressing covering an autograft is an anticipated abnormal observation postoperatively.

11. A sample consensus formula for fluid replacement recommends that a balanced salt solution be administered in the first 24 hours of a chemical burn in the range of 2 mL/kg/% of burn, with 50% of the total given in the first 8 hours postburn. A 176-lb (80-kg) man with a 30% burn should receive a minimum of how much fluid replacement in the first 8 hours? 4,800 mL 3,600 mL 1,200 mL 2,400 mL

2,400 mL Explanation: The ABA consensus formula provides for the volume of an isotonic solution (e.g., lactated Ringer's [LR]) to be administered during the first 24 hours in a range of 2 mL/kg/percentage TBSA. Half of the calculated total should be given over the first 8 postburn hours, and the other half should be given over the next 16 hours. Thus, the equation to find the minimum amount to infuse for this scenario is as follows: 2 mL × 80 kg × 30 = 4,800 mL of solution to be administered in the first 24 hours, with half this amount, 2,400 mL, to be administered in the first 8 hours.

19. A sample consensus formula for fluid replacement recommends that an isotonic solution be administered in the first 24 hours of a burn in the range of 2 to 4 mL/kg/% of burn with 50% of the total given in the first 8 hours postburn. A 176 lb (80 kg) man with a 30% burn should receive a minimum of how much fluid replacement in the first 8 hours? 4,800 mL 2,400 mL 1,200 mL 3,600 mL

2,400 mL Explanation: The minimum replacement is 2 mL/kg/%. Therefore, 2 mL × 80 kg = 160 mL × 30% = 4,800 mL. To give 50% in the first 8 hours, the nurse would give 2,400 mL.

10. 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? 18% 27% 9% 36%

36% Explanation: 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.

19. 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% 27% 18% 30%

36% Explanation: The Rule of Nines divides body surface area into percentages that, when totaled, equal 100%. According to the Rule of Nines, the arms account for 9% each, the anterior legs account for 9% each, and the anterior trunk accounts for 18%. Therefore, this client's burns cover 36% of the body surface area.

13. The nurse is applying an occlusive dressing to a burned foot. What position should the foot be placed in after application of the dressing? Dorsiflexion Plantar flexion External rotation Adduction

Adduction Explanation: When occlusive dressings are applied, precautions are taken to prevent two body surfaces from touching, such as fingers or toes, ear and scalp, the areas under the breasts, any point of flexion, or between the genital folds.

11. A nurse knows to assess a patient with a burn injury for gastrointestinal complications. Which of the following is a sign that indicates the presence of a paralytic ileus? Decreased peristalsis Fecal occult blood Hyperactive bowel sounds Hematemesis

Decreased peristalsis Explanation: Decreased peristalsis and hypoactive bowel sounds are manifestations of a paralytic ileus.

1. Which type of burn injury involves destruction of the epidermis and upper layers of the dermis as well as injury to the deeper portions of the dermis? Deep partial-thickness Superficial partial thickness Fourth degree Full-thickness

Deep partial-thickness Explanation: A deep partial-thickness burn involves destruction of the epidermis and upper layers of the dermis as well as injury to deeper portions of the dermis. In a superficial partial-thickness burn, the epidermis is destroyed or injured and a portion of the dermis may be injured. Capillary refill follows tissue blanching. Hair follicles remain intact. A full-thickness burn involves total destruction of epidermis and dermis and, in some cases, destruction of underlying tissue, muscle, and bone. Although the term fourth-degree burn is not used universally, it occurs with prolonged flame contact or high voltage injury that destroys all layers of the skin and damages tendons and muscles.

6. The nurse is caring for a client 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 if it occurs immediately after burn injury? Hypokalemia Hypercalcemia Hypernatremia Hyperkalemia

Hyperkalemia Explanation: Immediately after burn injury, hyperkalemia (excessive potassium) may result from massive cell destruction. Hypokalemia (potassium depletion) may occur later with fluid shifts and inadequate potassium replacement. During burn shock, serum sodium levels vary in response to fluid resuscitation. Hyponatremia (serum sodium depletion) may be present as a result of plasma loss. Hyponatremia may also occur during the first week of the acute phase, as water shifts from the interstitial space and returns to the vascular space.

4. Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is: Hypocalcemia. Hypernatremia. Hypoglycemia. Hyperkalemia.

Hyperkalemia. Explanation: Circulating blood volume decreases dramatically during burn shock due to severe capillary leak with variation of serum sodium levels in response to fluid resuscitation. Usually, hyponatremia (sodium depletion) is present. Immediately after burn injury, hyperkalemia (excessive potassium) results from massive cell destruction. Hypokalemia (potassium depletion) may occur later with fluid shifts and inadequate potassium replacement.

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

Hypotension Tachycardia Anxiety Explanation: Tachycardia, slight hypotension, and anxiety are expected soon after the burn.

16. The nurse receives a client following a serious thermal burn. Which complication will the nurse take action to prevent first? Renal failure Infection Tissue hypoxia Hypovolemia

Hypovolemia Explanation: 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.

3. A client recovering from burn injuries over both forearms reports itching of the wounds. Which action will the nurse take to enhance the client's comfort? Elevate the extremities above heart level. Provide pain medication as needed. Apply warm compresses over the areas. Instruct to pat and not scratch the areas.

Instruct to pat and not scratch the areas. Explanation: Post-burn pruritus (itching) affects almost all clients with burns and is one of the most distressing symptoms in the post-burn period. The client should be instructed to "pat, don't scratch" in order to prevent further discomfort and infectious complications. Other actions to reduce the itching include oral antipruritic agents, environmental conditions, frequent lubrication of the skin with water or silica-based lotion, and diversion activities. Warm compresses will enhance the itching. Elevating the extremities above the level of the heart helps reduce edema. Pain medication is not used to treat pruritis.

2. Which of the following site is the source of most microbes leading to bacterial infection? Intestinal tract Respiratory tract Mucous membranes Skin

Intestinal tract Explanation: When the wound is healing, it must be protected from infection. A primary source of bacterial infection is the patient's intestinal tract, the source of most microbes. The respiratory tract, skin, and mucous membranes are not the source of most microbes.

9. The nurse is administering an analgesic to a patient with major burns. What is the recommended route for administration for this patient? Subcutaneous Intravenous Intramuscular Oral

Intravenous Explanation: Intravenous administration is necessary because of altered tissue perfusion from burn injury.

10. 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? Avoid immediate IV fluid therapy. Place the client with the head positioned slightly below the rest of the body. Cover the client with a wet cloth. Roll the client in a blanket.

Roll the client in a blanket. Explanation: When clothing catches fire, the flames can be extinguished if the person drops to the floor or ground and rolls ("stop, drop, and roll"); anything available to smother the flames, such as a blanket, rug, or coat, may be used. The older adult, or others with impaired mobility, could be instructed to "stop, sit, and pat" to prevent concomitant musculoskeletal injuries. The client should not be covered immediately with a wet cloth or kept in any position other than horizontal. However, IV fluid therapy should be administered en route to the hospital.

6. Determining the depth of a burn is difficult initially because there are combinations of injury zones in the same location. The area of intermediate burn injury is the zone in which blood vessels are damaged, but tissue has the potential to survive. This is called the zone of: hyperemia. coagulation. stasis. hypotension.

Stasis. Explanation: The zone of stasis is the area of intermediate burn injury. It is here that blood vessels are damaged, but tissue has the potential to survive. The zone of coagulation is at the center of the injury, and it is the area where the injury is most severe and usually deepest. The zone of hyperemia is the area of least injury, where the epidermis and dermis are only minimally damaged. The zone of hypotension is not the name of one of the zones.

17. The nurse is providing wound care for a client with burns to the lower extremities. Which topical antibacterial agent carries a side effect of leukopenia that the nurse should monitor for within 48 hours after application? Cerium nitrate solution Mafenide (Sulfamylon) Gentamicin sulfate Sulfadiazine, silver (Silvadene)

Sulfadiazine, silver (Silvadene) Explanation: With use of silver sulfadiazine (Silvadene), the nurse should watch for leukopenia 2 to 3 days after initiation of therapy. (Leukopenia usually resolves within 2 to 3 days.)

5. Which of the following is a potential cause of a superficial partial-thickness burn? Electrical current Sunburn Flash flame Scald

Sunburn Explanation: A potential cause of a superficial partial-thickness burn is a sunburn or low-intensity flash. Causes of deep partial-thickness burns are scalds and flash flames. Full-thickness burns may be caused by an electrical current or prolonged exposure to hot liquids.

3. 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? Full-thickness Deep partial-thickness Superficial partial-thickness Superficial

Superficial Explanation: A superficial burn only damages the epidermis. A full-thickness burn involves total destruction of the dermis and extends into the subcutaneous fat. It can also involve muscle and bone. In a superficial partial-thickness burn, the epidermis is destroyed and a small portion of the underlying dermis is injured. A deep partial-thickness burn extends into the reticular layer of the dermis and is hard to distinguish from a full-thickness burn. It is red or white, mottled, and can be moist or fairly dry.

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

The client has experienced extensive full-thickness burns. Explanation: 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.

15. As the first priority of care, a patient with a burn injury will initially need: a patent airway established. fluids replaced. an indwelling catheter inserted. pain medication administered.

a patent airway established. Explanation: Breathing must be assessed and a patent airway established immediately during the initial minutes of emergency care. Immediate therapy is directed toward establishing an airway and administering humidified 100% oxygen.

10. 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. Which graft is described as a biologic source of skin similar to that of the client? slit graft autograft allograft xenograft

allograft Explanation: Allograft or homograft is a biologic source of skin similar to that of the client. A xenograft or heterograft is obtained from animals, principally pigs or cows. An autograft uses the client's own skin, transplanted from one part of the body to another. A slit graft is a type of autograft.

1. The nurse recognizes the first dressing change at the site of an autograft is performed as soon as sanguineous drainage is noted. as soon as foul odor or purulent drainage is noted, or 2 to 5 days after surgery. within 12 hours after surgery. within 24 hours after surgery.

as soon as foul odor or purulent drainage is noted, or 2 to 5 days after surgery. Explanation: A foul odor or purulent drainage may indicate infection and should be reported to the surgeon immediately. The first dressing change usually occurs 2 to 5 days after surgery. Sanguineous drainage on a dressing covering an autograft is an anticipated abnormal observation postoperatively.

7. The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories. The nurse recognizes this intervention is to promote increased skeletal muscle breakdown. increased metabolic rate. increased glucose demands. decreased catabolism.

decreased catabolism Explanation: Burn injuries produce profound metabolic abnormalities fueled by the exaggerated stress response to the injury. The body's response has been classified as hyperdynamic, hypermetabolic, and hypercatabolic. The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to decrease catabolism. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50%. A marked increase in metabolic rate is seen after a burn injury and interventions are instituted to decrease metabolic rate and catabolism. A marked increase in glucose demand is seen after a burn injury and interventions are instituted to decrease glucose demands and catabolism. Rapid skeletal muscle breakdown with amino acids serving as the energy source is seen after a burn injury and interventions are instituted to decrease catabolism.

3. 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? allograft silvadene application debridement escharotomy

escharotomy Explanation: Debridement is the removal of necrotic tissue. An escharotomy is an incision into the eschar to relieve pressure on the affected area. An allograft would not be the treatment. Silvadene may be part of the treatment regimen but not specifically for this situation.

14. 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 leathery. How would the nurse document the depth of burn injury this client has? superficial partial-thickness or deep partial-thickness (second degree) superficial (first degree) fourth degree full thickness (third degree)

full thickness (third degree) Explanation: Full-thickness (third degree) burn destroys all layers of the skin and consequently is painless. The tissue appearance varies and can be dry, pale white, red, brown, leathery, charred or lifeless. Superficial (first degree) burn is similar to a sunburn. The epidermis is injured, but the dermis is unaffected. Superficial partial-thickness burn heals within 14 days, with possibly some pigmentary changes but no scarring. The deep partial-thickness (second degree) burn takes more than 3 weeks to heal, may need debridement, and is subject to hypertrophic scarring. A fourth-degree burn can involve ligaments, tendons, muscles, nerves, and bone.