burns

The nurse is conducting a focused assessment of the gastrointestinal system of a client with a burn injury. What should the nurse assess? A Gastric distention B Curling's ulcer C Hiatal hernia D Paralytic ileus

Correct Answer: Curling's ulcer Explanation: Curling's ulcer, or gastrointestinal ulceration, occurs in about half of the clients with a burn injury. The incidence of ulceration appears proportional to the extent of the burns, and the ulceration is believed to be caused by hypersecretion of gastric acid and compromised gastrointestinal perfusion. Paralytic ileus and gastric distention do not result from hypersecretion of gastric acid and stress and thus are not expected findings at this time. Hiatal hernia is not necessarily a potential complication of a burn injury.

The nurse is caring for a child with moderate burns from the waist down. Which measure should the nurse implement when positioning the child? A Allow the child to lie on the abdomen. B Place the child in a position of comfort. C Have the child flex the hips and knees. D Ensure the application of leg splints.

Correct Answer: Ensure the application of leg splints. Explanation: A child with moderate burns is at high risk for contractures. A position of comfort would encourage contracture formation. Therefore, splints need to be applied to maintain proper positioning and joint function, thereby preventing contractures and loss of function. Allowing the child to lie on the abdomen or with the hips and knees flexed often encourages contracture formation.

16. You're providing education to a group of local firefighters about carbon monoxide poisoning. Which statement is correct about the pathophysiology regarding this condition? A. "Patients are most likely to present with cyanosis around the lips and face." B. "In this condition, carbon monoxide binds to the hemoglobin of the red blood cell leading to a decrease in the ability of the hemoglobin to carry oxygen to the body." C. "Carbon monoxide poisoning leads to a hyperoxygenated state, which causes hypercapnia." D. "Carbon monoxide binds to the hemoglobin of the red blood cell and prevents the transport of carbon dioxide out of the blood, which leads to poisoning."

The answer is B. This is the only correct statement about carbon monoxide poisoning

The client with a major burn injury receives total parenteral nutrition (TPN). What is the expected outcome of TPN? A Ensure adequate caloric and protein intake B Allow the gastrointestinal tract to rest C Correct water and electrolyte imbalances D Provide supplemental vitamins and minerals

Correct Answer: Ensure adequate caloric and protein intake Explanation: Nutritional support with sufficient calories and protein is extremely important for a client with severe burns because of the loss of plasma protein through injured capillaries and an increased metabolic rate. Gastric dilation and paralytic ileus commonly occur in clients with severe burns, making oral fluids and foods contraindicated. Water and electrolyte imbalances can be corrected by administration of IV fluids with electrolyte additives, although TPN typically includes all necessary electrolytes. Resting the gastrointestinal tract may help prevent paralytic ileus, and TPN provides vitamins and minerals; however, the primary reason for starting TPN is to provide the protein necessary for tissue healing.

Intravenous (IV) morphine sulfate is prescribed for an early adolescent girl hospitalized with major burns to 30% of her body. A licensed practical nurse (LPN) asks the registered nurse (RN) why the morphine is given by the IV route when the child can talk and swallow. The RN should explain to the LPN that, when given by the IV route, morphine does which of the following? A Prevents ileus B Leads to fewer side effects C Has a predictable absorption rate D Has a longer half-life

Correct Answer: Has a predictable absorption rate Explanation: The predictable rate of absorption makes IV morphine useful in treating severe pain. As part of the physiological stress response, blood is shunted away from the gastrointestinal tract, making the oral absorption rates less predictable. The half-life of the drug is not relevant to the question asked. The IV route will not prevent ileus. The IV route may actually have greater side effects because of rapid onset of action.

A client is receiving fluid replacement with lactated Ringer's after 40% of the body was burned 10 hours ago. The assessment reveals temperature 97.1°F (36.2°C), heart rate 122 bpm, blood pressure 84/42 mm Hg, central venous pressure (CVP) 2 mm Hg, and urine output 25 mL for the last 2 hours. The IV rate is currently at 375 mL/h. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, what prescription should the nurse request from the health care provider? A Fresh frozen plasma B IV rate increase C Furosemide D Dextrose 5%

Correct Answer: IV rate increase Explanation: The decreased urine output, low blood pressure, low CVP, and high heart rate indicate hypovolemia and the need to increase fluid volume replacement. Furosemide is a diuretic that should not be given due to the existing fluid volume deficit. Fresh frozen plasma is not indicated. It is given for clients with deficient clotting factors who are bleeding. Fluid replacement used for burns is lactated Ringer's solution, normal saline, or albumin.

In the acute phase of burn injury, which pain medication would most likely be given to the client to decrease the perception of the pain? A Intramuscular opioids B Oral analgesics such as ibuprofen or acetaminophen C Oral antianxiety agents such as lorazepam D Intravenous opioids

Correct Answer: Intravenous opioids Explanation: The severe pain experienced by burn clients requires opioid analgesics. In addition, opioids such as morphine sedate and alleviate apprehension. Oral analgesics such as ibuprofen or acetaminophen are unlikely to be strong enough to effectively manage the intense pain experienced by the client who is severely burned. Because of the altered tissue perfusion from the burn injury, intravenous medications are preferred. Antianxiety agents are not effective against pain.

When caring for a client with a burn in the emergent/resuscitative stage of burn injury, which factor has lowest priority with respect to burn assessment at this time? A Extent of burn injury B Measures used to debride the burn wound C First-aid treatment given D Cause of the burn

Correct Answer: Measures used to debride the burn wound Explanation: Knowledge of debridement methods is a lower priority because this information does not directly influence the plan of care. In the emergent/resuscitative stage, the nurse assesses the cause and extent of the burn, which provides information that guides treatment and nursing care. In the emergent/resuscitative stage, the nurse initiates prescribed fluid resuscitation therapies to stabilize the client's hemodynamic status. In the emergent/resuscitative stage, the nurse needs to know first aid measures that were used as a guide to continuing therapy.

After the initial phase of the burn injury, what goals should the nurse establish with the client? A Preventing infection B Educating the client regarding care of the skin grafts C Promoting hygiene D Helping the client maintain a positive self-concept

Correct Answer: Preventing infection Explanation: The inflammatory response begins when a burn is sustained. As a result of the burn, the immune system becomes impaired. There is a decrease in immunoglobulins, changes in white blood cells, alterations of lymphocytes, and decreased levels of interleukin. The human body's protective barrier, the skin, has been damaged. As a result, the burn client becomes vulnerable to infections. Education and interventions to maintain a positive self-concept would be appropriate during the rehabilitation phase. Promoting hygiene helps the client feel comfortable; however, the primary focus is on reducing the risk for infection.

Which is an advantage of using biologic burn grafts such as porcine (pigskin) grafts? Porcine grafts: A encourage the formation of tough skin. B facilitate the development of subcutaneous tissue. C provide for permanent wound closure. D promote the growth of epithelial tissue.

Correct Answer: promote the growth of epithelial tissue. Explanation: Biologic dressings such as porcine grafts serve many purposes for a client with severe burns. They enhance the growth of epithelial tissues, minimize the overgrowth of granulation tissue, prevent loss of water and protein, decrease pain, increase mobility, and help prevent infection. They do not encourage growth of tougher skin, provide for permanent wound closure, or facilitate growth of subcutaneous tissue.

13. The nurse notes a patient has full-thickness circumferential burns on the right leg. The nurse would: select all that apply A. Place cold compressions on the burn and elevate the right leg below the heart level B. Assess the distal pulses in the right extremity C. Elevate the right leg above the heart level D. Place gauze securely around the leg to prevent infection The answer is B and C. The patient has burns that completely surround the front and back of the right leg. This can lead to compartment syndrome where the edema from the burn compromises circulation to the distal extremity. The nurse should elevate the extremity ABOVE heart level to decrease swelling and assess distal pulses in the extremity to confirm circulation is present.

The answer is B and C. The patient has burns that completely surround the front and back of the right leg. This can lead to compartment syndrome where the edema from the burn compromises circulation to the distal extremity. The nurse should elevate the extremity ABOVE heart level to decrease swelling and assess distal pulses in the extremity to confirm circulation is present.

11. A patient has experienced full-thickness burns to the face and neck. As the nurse it is priority to: A. Prevent hypothermia B. Assess the blood pressure C. Assess the airway D. Prevent infection

The answer is C. Due to the location of the burns (face and neck), the patient is at major risk for respiratory issues due to damage to the upper airways and the risk of an inhalation injury.

The nurses teaches the parent of a child with severe burns about the importance of specific nutritional support in burn management. The nurse recognizes the need for more teaching if the parents select which food for their child? A Bacon, lettuce, and tomato sandwich; milk; and celery and carrot sticks B Chicken nuggets; orange and grapefruit sections; and a vanilla milkshake C Beef, bean, and cheese burrito; a banana; fruit-flavored yogurt; and skim milk D Cheeseburger; cottage cheese and pineapple salad; chocolate milk; and a brownie

Correct Answer: Bacon, lettuce, and tomato sandwich; milk; and celery and carrot sticks Explanation: Hypoproteinemia is common after severe burns. The child's diet should be high in protein to compensate for protein loss and to promote tissue healing. The child will also require a diet that is high in calories and rich in iron. The menu of bacon, lettuce, and tomato sandwich; milk; and celery sticks is lacking in sufficient protein and calories.

The emergency department (ED) nurse hears a radio transmission from an ambulance stating that a 10-year-old boy who sustained partial-thickness burns to his right arm and abdomen after tossing gasoline on a fire is on the way. On arrival to the ED, the nurse should expect the burn site to have which appearance? A Smooth and bright red B Bright red with numerous blisters C Dark brown and firm D White and waxy

Correct Answer: Bright red with numerous blisters Explanation: The anticipated appearance of partial-thickness burns is bright red skin with blisters of varying sizes. A superficial burn typically only has pink or red skin. A full-thickness burn may be dark in color, from deep red to black.

14. A patient arrives to the ER with full-thickness burns on the front and back of the torso and neck. The patient has no spinal injuries but is disoriented and coughing up black sooty sputum. Vital signs are: oxygen saturation 63%, heart rate 145, blood pressure 80/56, and respiratory rate 39. As the nurse you will: A. Place the patient in High Fowler's positon. B. Prep the patient for escharotomy. C. Prep the patient for fasciotomy. D. Prep the patient for intubation. E. Place a pillow under the patient's neck. F. Obtain IV access at two sites. G. Restrict fluids.

The answers are A, B, D, and F. After reading this scenario the location of the burns and the patient's presentation should be jumping out at you. The patient is at risk for circumferential burns due to the location of the burns and the depth (full-thickness....will have eschar present that will restrict circulation or here in this example the ability of the patient to breathe in and out). Based on the patient's VS, we see that the respiratory effort is compromised majorly AND that there is a risk of inhalation injury since the patient is coughing up black sooty sputum. Therefore, the nurse should place the patient in high Fowler's position to help with respiratory effort (unless contraindicated with spinal injuries), prep the patient for escharotomy (this will cut the eschar and help relieve pressure and allow for breathing) and prep for intubation to help with the respiratory distress. In addition, obtain IV access in at least two sites for fluid replacement....remember the first 24 hours after a burn a patient is at risk for hypovolemic shock.

The nurse is caring for a client with severe burns who is receiving fluid resuscitation. Which finding indicates that the client is responding to the fluid resuscitation? A Pulse rate of 112 bpm B Blood pressure of 94/64 mm Hg C Urine output of 30 mL?h D Serum sodium level of 136 mEq/L (136 mmol/L)

Correct Answer: Urine output of 30 mL?h Explanation: Ensuring a urine output of 30 to 50 mL/h is the best measure of adequate fluid resuscitation. The heart rate is elevated, but this is not an indicator of adequate fluid balance. The blood pressure is low, likely related to the hypovolemia, but urinary output is the more accurate indicator of fluid balance and kidney function. The sodium level is within normal limits.

10. A patient has a burn on the back of the torso that is extremely red and painful but no blisters are present. When you pressed on the skin it blanches. You document this as a: A. 1st degree (superficial) burn B. 2nd degree (partial-thickness) burn C. 3rd degree (full-thickness) burn D. 4th degree (deep full-thickness) burn

The answer is A. These are the classic characteristics of a 1st degree, superficial burn.

The nurse is caring for a client with full-thickness burns on 50% of his body. The client's partner asks, "Why does he look so different? He's all puffy." What is the best response by the nurse? A "It is normal at this stage of a burn injury." B "The burn causes his fluids to shift into his tissues and that is causing the puffiness." C "We are giving him a great deal of intravenous solution and that is causing the edema." D "When he receives his diuretic, most of the puffiness will go away."

Correct Answer: "The burn causes his fluids to shift into his tissues and that is causing the puffiness." Explanation: After a burn, the blood vessels dilate and fluid leaks into the interstitial spaces. This is known as third spacing, and appears as edema or "puffiness" as described by the client's partner. Fluid shifts are treated with large volumes of intravenous fluids to maintain the circulating blood volume, but this is not the initial cause of the edema. To state that the client's appearance is normal at this stage in a burn injury does not provide the client's partner with an explanation; it is a dismissive response. Edema will continue until the fluid is reabsorbed from the interstitium into the intravascular compartment.

A client has burns on both hands and upper arms. Which nursing actions will be most helpful in preventing contractures? Select all that apply. A Apply splints as prescribed. B Apply moisturizer to the hands and fingers. C Keep the hands elevated. D Administer narcotic pain medications every 3 hours. E Collaborated with the physical therapist. F Wash the fingers, hands, and upper arms with cool water.

Correct Answers: Collaborated with the physical therapist. Apply splints as prescribed. Keep the hands elevated. Explanation: The most helpful strategies to prevent and manage contractures when a client has burns of the hands are to keep the hands elevated, use hand splints, and physical therapy. The nurse should collaborate with the entire burn team to prevent contractures. The nurse should administer pain medication and provide hygiene measures as prescribed, but these do not directly prevent contractures. The nurse should check with the health care provider before applying moisturizer or other substances to the burned area.

2. True or False: A patient who experiences an alkali chemical burn is easier to treat because the skin will neutralize the chemical rather than with an acidic chemical burn. True False

False: Alkali burns are harder to treat than acidic chemical burns because the skin will neutralize the acidic burn.

18. What are some patient priorities during the emergent phase of burn management? A. Fluid volume B. Respiratory status C. Psychosocial D. Wound closure E. Nutrition

The answer is A and B. This phase starts from the onset of the burn and ends with the restoration of capillary permeability. Wound closure, and nutrition would be during the acute phase, and would continue into the rehabilitative phase. Psychosocial would be in the rehab phase.

28. You are about to provide care to a patient with severe burns. You will don: A. gloves B. goggles C. gown D. N-95 mask E. surgical mask F. shoe covers G. hair cover

The answer is A, C, E, F, and G. Before providing care to a patient with severe burns the nurse would want to wear protective isolation apparel like: gloves, gown, surgical mask, shoe covers, and hair cover. This protects the patient from potential infection.

25. A patient has an emergency escharotomy performed on the right leg. The patient has full-thickness circumferential burns on the leg. Which finding below demonstrates the procedure was successful? A. The patient can move the extremity. B. The right foot's capillary refill is less than 2 seconds. C. The patient reports a new sensation of extreme pain. D. The patient has a positive babinski reflex.

The answer is B. Escharotomy is performed when a full-thickness burn, due to eschar (which is burned tissue that is hard), is compromising blood flow to the distal extremity. The eschar is cut and this relieves pressure and allows blood to flow to the extremity.

30. A patient is presenting with bright red lips, headache, and nausea. The physician suspects carbon monoxide poisoning. As the nurse, you know the patient needs: A. Oxygen nasal cannula 5-6 Liters B. 100% oxygen via non-rebreather mask C. Continuous Bipap D. Venturi mask 6 L oxygen

The answer is B. This is the treatment for carbon monoxide poisoning.

A client with burns is to have a whirlpool bath and dressing change. What should the nurse do 30 minutes before the bath? A Soak the dressing. B Administer an analgesic. C Remove the dressing. D Slit the dressing with blunt scissors.

Correct Answer: Administer an analgesic. Explanation: Removing dressings from severe burns exposes sensitive nerve endings to the air, which is painful. The client should be given a prescribed analgesic about one-half hour before the dressing change to promote comfort. The other activities are done as part of the whirlpool and dressing change process and not one-half hour beforehand.

19. During the emergent phase of burn management, you would expect the following lab values: A. Low sodium, low potassium, high glucose, low hematocrit B. High sodium, low potassium, low glucose, high hematocrit C. High sodium, high potassium, high glucose, low hematocrit D. Low sodium, high potassium, high glucose, high hematocrit

The answer is D. Think about the increase in the capillary permeability that happens with severe burns, which causes the plasma to leave the intravascular system and enter the interstitial tissue: Low sodium..why: sodium leaves with the plasma to the interstitial tissue and drops the levels in the blood; High potassium...why? damaged cells lysis and leak potassium which increases the leave in the blood; high glucose...why? stress response leads the liver to release glycogen and this increases levels; high hematocrit...why? when the plasma leaves the intravascular system (the fluid) it causes the blood to become more concentrated so hematocrit increases (this will decrease when the patient's fluid is replaced).

1. A 65 year old male patient has experienced full-thickness electrical burns on the legs and arms. As the nurse you know this patient is at risk for the following: Select all that apply: A. Acute kidney injury B. Dysrhythmia C. Iceberg effect D. Hypernatremia E. Bone fractures F. Fluid volume overload

The answers are A, B, C, and E. Electric burns are due to an electrical current passing through the body that leads to damage to the skin but also the muscles and bones that are underneath the skin. The patient is at risk for AKI (acute kidney injury) because when the muscles become affected they release myoglobin and the red blood cells release hemoglobin in the blood, which can collect in the kidneys leading to injury. In addition, the heart's electrical system can become damaged leading to dysrhythmia. The iceberg effect can present as well because the extent of damage is not clearly visible on the skin (there can be severe damage underneath). In addition, if the electrical current is strong enough it can lead to bone fractures (specifically cervical spine injuries) due to the severe contraction of the muscles involved.

When should the nurse initiate rehabilitation plans for the client who has severe burns? A After the client's pain has been eliminated B After grafting of the burn wounds has occurred C After the client's circulatory status has been stabilized D Immediately after the burn has occurred

Correct Answer: After the client's circulatory status has been stabilized Explanation: Rehabilitation efforts are implemented as soon as the client's condition is stabilized. Early emphasis on rehabilitation is important to decrease complications and to help ensure that the client will be able to make the adjustments necessary to return to an optimal state of health and independence. It is not possible to completely eliminate the client's pain; pain control is a major challenge in burn care.

Which client with burns will most likely require an endotracheal or tracheostomy tube? A client who has: A electrical burns of the hands and arms causing arrhythmias. B thermal burns to the head, face, and airway resulting in hypoxia. C chemical burns on the chest and abdomen. D secondhand smoke inhalation.

Correct Answer: thermal burns to the head, face, and airway resulting in hypoxia. Explanation: Airway management is the priority in caring for a burn client. Tracheostomy or endotracheal intubation is anticipated when significant thermal and smoke inhalation burns occur. Clients who have experienced burns to the face and neck usually will be compromised within 1 to 2 hours. Electrical burns of the hands and arms, even with cardiac arrhythmias, or a chemical burn of the chest and abdomen is not likely to result in the need for intubation. Secondhand smoke inhalation does influence an individual's respiratory status but does not require intubation unless the individual has an allergic reaction to the smoke.

21. A patient who is being treated for partial thickness burns on 60% of the body is now in the acute phase of burn management. The nurse assesses the patient for a possible Curling's Ulcer. What signs and symptoms can present with this condition? A. Swelling and pain on the area distal to the burn B. Burning, gnawing sensation pain in the stomach and vomiting C. Dark red or gray sores on the soles of the feet D. Difficulty swallowing and gagging

The answer is B. This is a type of ulcer that occurs in the stomach, duodenum, due to a high amount of stress on the body from a burn. The blood supply to the factors that help protect the stomach lining from gastric erosion decreases and this allows for ulcers to form.

8. A 58 year old female patient has superficial partial-thickness burns to the anterior head and neck, front and back of the left arm, front of the right arm, posterior trunk, front and back of the right leg, and back of the left leg. Using the Rule of Nines, calculate the total body surface area percentage that is burned? A. 63% B. 81% C. 72% D. 54%

The answer is A. Anterior head and neck (4.5%), front and back of the left arm (9%), front of the right arm (4.5%), posterior trunk (18%), front and back of the right leg (18%), back of the left leg (9%) which equals 63%.

3. As the nurse providing care to a patient who experienced a full-thickness electrical burn you know to monitor the patient's urine for: A. Hemoglobin and myoglobin B. Free iron and white blood cells C. Protein and red blood cells D. Potassium and Urea

The answer is A. Patients who've experienced a severe electrical burn or full-thickness burns are at risk for acute kidney injury. This is because the muscles can experience damage from the electrical current leading them to release myoglobin. In addition, the red blood cells will release hemoglobin. These substances will collect in the kidneys leading to acute tubular necrosis (hence leading to AKI). Therefore, the nurse should monitor the patient's urine for these substances.

24. A patient has full-thickness burns on the front and back of both arm and hands. It is nursing priority to: A. Elevate and extend the extremities B. Elevate and flex the extremities C. Keep extremities below heart level and extended D. Keep extremities level with the heart level and flexed

The answer is A. This position will decrease edema, which will help prevent compartment syndrome.

29. While collecting a medical history on a patient who experienced a severe burn, which statement by the patient's family member requires nursing intervention? A. "He takes medication for glaucoma". B. "I think it has been 10 years or more since he had a tetanus shot." C. "He was told he had COPD last year." D. "He smokes 2 packs of cigarettes a day."

The answer is B. Patients who have had burns need a tetanus shot if they have not had a vaccine within the past 5 to 10 years.

5. The _____________ layer of the skin helps regulate our body temperature. A. Epidermis B. Dermis C. Hypodermis D. Fascia

The answer is C. This layer contains fatty tissue, veins, arteries, nerves and helps insulate the muscles, bones, organs and helps REGULATE our body temperature.

A 5-year-old boy was brought to the emergency department after being burned trying to put out a fire in his closet, where he was playing with matches. What should be the priority nursing assessment for this child? A Signs of infection B Airway patency C Level of pain D Psychosocial needs

Correct Answer: Airway patency Explanation: Because he was in close proximity to the fire and tried to put it out, he is at risk of having inhaled smoke and, therefore, having a compromised airway. Other physiological signs, such as pain, will be of second highest priority. Psychosocial concerns are addressed once physiological needs have been met. Infection would be a third priority because it would not happen immediately.

23. You're assisting the nursing assistant with repositioning a patient with full-thickness burns on the neck. Which action by the nursing assistant requires you to intervene? A. The nursing assistant elevates the head of the bed above 30 degrees. B. The nursing assistant places a pillow under the patient's head. C. The nursing assistant places rolled towels under the patient's shoulders. D. The nursing assistant covers the patient with sterile linens.

The answer is B. If a patient has severe burns to the neck (head as well) a pillow should NOT be used under the head because this can cause wound contractions. Instead rolled towels should be placed under the shoulders.

20. A patient is receiving IV Lactated Ringers 950 mL/hr post 18 hours after a receiving a severe burn. The patient urinary output is 20 mL/hr. As the nurse your next nursing action is to: A. Increase the IV fluids B. Continue to monitor the patient C. Decrease the IV fluids D. Notify the physician of this finding

The answer is D. The patient's urinary output is too low and needs more fluids. It should be at least 30 mL/hr. Therefore, the nurse must notify the physician for further orders. The nurse can NOT increase or decrease IV fluids without a physician's order.

15. A patient arrives to the ER due to experiencing burns while in an enclosed warehouse. Which assessment findings below demonstrate the patient may have experienced an inhalation injury? A. Carbonaceous sputum B. Hair singeing on the head and nose C. Lhermitte's Sign D. Bright red lips E. Hoarse voice F. Tachycardia

The answers are A, B, D, E, and F. These are all signs of a possible inhalation injury. Bright red lips and tachycardia are present in carbon monoxide poisoning as well.

A school-age child with burns on the trunk and arms has no appetite. The nurse and the parent develop a plan of care to stimulate the child's appetite. Which suggestion made by the parent would indicate the need for additional teaching? A Offering the child finger foods that the child likes B Withholding dessert and treats unless meals are eaten C Serving smaller and more frequent meals D Deciding that she will feed the child herself

Correct Answer: Withholding dessert and treats unless meals are eaten Explanation: Withholding certain foods until the child complies is punitive and rarely successful. Allowing the mother to feed the child, serving smaller and more frequent meals, and offering finger foods are all acceptable interventions for a 5-year-old child. This is true whether the child is well or ill.

12. A patient is in the acute phase of burn management. The patient experienced full-thickness burns to the perineum and sacral area of the body. In the patient's plan of care, which nursing diagnosis is priority at this time? A. Impaired skin integrity B. Risk for fluid volume overload C. Risk for infection D. Ineffective coping

The answer is C. The patient is now in the acute phase where fluid resuscitation was successful and ends with wound closure. Therefore, during this stage diuresis occurs (so fluid volume deficient could occur NOT overload) and INFECTION. The location of the burns increases the risk of infection because these areas naturally harbor bacteria. Therefore, this takes priority because during this phase wound healing is promoted.

7. Based on the depth of the burn in figure 1 (picture is above), you would expect to find: A. report of sensation to only pressure B. blanching C. anesthetization to feeling D. extreme pain

The answer is C. This is a 3rd degree to 4th degree burn (full-thickness) and the nerves that detect pain are destroyed. The patient would have no feeling or experiences an extreme decrease sensation to pain.

The nurse is assessing an 80-year-old client who has scald burns on the hands and both forearms (first- and second-degree burns on 10% of the body surface area). What should the nurse do first? A Cover the burns with a sterile dressing. B Clean the wounds with warm water. C Apply antibiotic cream. D Refer the client to a burn center.

Correct Answer: Refer the client to a burn center. Explanation: The nurse should have the client transported to a burn center. The client's age and the extent of the burns require care by a burn team, and the client meets triage criteria for referral to a burn center. Because of the age of the client and the extent of the burns, the nurse should not treat the burn. Scald burns are not at high risk for infection and do not need to be cleaned, covered, or treated with antibiotic cream at this time.

22. During the acute phase of burn management, what is the best diet for a patient who has experienced severe burns? A. High fiber, low calories, and low protein B. High calorie, high protein and carbohydrate C. High potassium, high carbohydrate, and low protein D. Low sodium, high protein, and restrict fluids to 1 liter per day

The answer is B. This type of diet promotes wound healing and meets the caloric demands of the body.

There has been a fire in an apartment building. All residents have been evacuated, but many are burned. Which clients should be transported immediately to a burn center for treatment? Select all that apply. A A 30-year-old with second-degree burns on the back of the left leg (about 9% of BSA) B A 50-year-old diabetic with first- and second-degree burns on the left forearm (about 5% of BSA) C A 40-year-old with second-degree burns on the right arm (about 10% of BSA) D A 20-year-old who inhaled the smoke of the fire E An 8-year-old with third-degree burns over 10% of the body surface area (BSA)

Correct Answers: A 50-year-old diabetic with first- and second-degree burns on the left forearm (about 5% of BSA) A 20-year-old who inhaled the smoke of the fire An 8-year-old with third-degree burns over 10% of the body surface area (BSA) Explanation: Clients who should be transferred to a burn center include children under age 10 or adults over age 50 with second- and third-degree burns on 10% or greater of their BSA, clients between ages 11 and 49 with second- and third-degree burns over 20% of their BSA, clients of any age with third-degree burns on more than 5% of their BSA, clients with smoke inhalation, and clients with chronic diseases, such as diabetes and heart or kidney disease.

A client has a full-thickness burn that has stopped healing. For which causative factors should the nurse assess? Select all that apply. A Presence of granulation B Impaired circulation C Exaggerated immune response D Nutritional deficit E Infection

Correct Answers: Infection Nutritional deficit Impaired circulation Explanation: Wound healing requires the presence of adequate nutrients and oxygen. A burn interferes with circulation. The presence of an infection uses some of those resources and physically interferes with the formation of new tissue and wound closure. Impaired immune responses are associated with impaired healing. Granulation is the formation of new tissue and indicates healing is occurring.

6. You receive a patient who has experienced a burn on the right leg. You note the burn contains small blisters and is extremely pinkish red and shiny/moist. The patient reports severe pain. You document this burn as: A. 1st Degree (superficial) B. 2nd Degree (partial-thickness) C. 3rd Degree (full-thickness) D. 4th Degree (deep full-thickness)

The answer is B. These are the classic characteristics of a 2nd degree (partial-thickness) burn.

Which interventions would be most appropriate to institute when a school-age child with burns becomes angry and combative when it is time to change the dressings and apply mafenide acetate? A Give the child permission to cry during the procedure. B Allow the child to assist in removing the dressings and applying the cream. C Ensure parental support during the dressing changes. D Allow the child to schedule the time for dressing changes.

Correct Answer: Allow the child to assist in removing the dressings and applying the cream. Explanation: Expressions of anger and combativeness are often the result of loss of control and a feeling of powerlessness. Some control over the situation is regained by allowing the child to participate in care. Although having parental support during the dressing changes may be helpful, this action does nothing to allow the child control. Giving the child permission to cry may help with verbalizing feelings, but doing so does nothing to provide the child with control over the situation. Although allowing the child to determine the time for dressing changes may provide a sense of control over the situation, doing so is inappropriate because the dressing changes need to be performed as prescribed to ensure effectiveness and healing.

A client is admitted with a 45% partial and full thickness burn. Which finding would alert the nurse that the client has a deficiency in fluid volume during the first 24 hours? A Oxygen saturation of 94% B Serum creatinine of 1.1 mg/dL (97.2 μmol/L) C Urine output of <30 mL/h D Serum potassium level of 3.7 mEq/L

Correct Answer: Urine output of <30 mL/h Explanation: It is critical that the nurse monitor the vital signs, hemodynamics and urine output during the emergent and resuscitative phase of the burn injury. The urine output of <30 mL/h is an indication of hypovolemia in this client. The serum creatinine, serum potassium, and the oxygen saturation level are all within acceptable limits.

27. After receiving report on a patient receiving treatment for severe burns, you perform your head-to-toe assessment. On arrival to the patient's room you note the room temperature to be 75'F. You will: A. Decrease the temperature by 5-10 degrees to prevent hyperthermia. B. Leave the temperature setting. C. Increase the temperature to a minimum of 85'F.

The answer is C. Patients with severe burns can NOT regulate their temperature and are at risk for hypothermia. The room temperature should be a minimum of 85'F.

26. Your patient with severe burns is due to have a dressing change. You will pre-medicate the patient prior to the dressing change. The patient has standing orders for all the medications below. Which medication is best for this patient? A. IM morphine B. PO morphine C. IV morphine D. Subq morphine

The answer is C. The best route that is predictable and easily absorbed is via the IV route in burn victims.

A child has been admitted to the burn unit with a circumferential burn to the right leg. How should the nurse position the client? A With the right leg dependent B On the left side C Flat in bed D With the right leg elevated

Correct Answer: With the right leg elevated Explanation: The fluid shift that occurs in burns leads to edema, so the burned extremity should always be elevated above the level of the heart. Positioning the client flat in bed does not make use of gravity to reduce edema. An extremity that is in a dependent position is below heart level. While lying on the left side is of some help with a right leg burn, it does not provide the best elevation to reduce the risk of developing edema.

During the emergent (resuscitative) phase of burn injury, which finding indicates that the client requires additional volume with fluid resuscitation? A Serum creatinine level of 2.5 mg/dL (221 μmol/L) B Serum albumin level of 3.8 mg/dL (38 g/L) C Little fluctuation in daily weight D Hourly urine output of 60 mL

Correct Answer: Serum creatinine level of 2.5 mg/dL (221 μmol/L) Explanation: Fluid shifting into the interstitial space causes intravascular volume depletion and decreased perfusion to the kidneys. This would result in an increase in serum creatinine. Urine output should be frequently monitored and adequately maintained with intravenous fluid resuscitation that would be increased when a drop in urine output occurs. Urine output should be at least 30 mL/h. Fluid replacement is based on the Parkland or Brooke formula and also the client's response by monitoring urine output, vital signs, and CVP readings. Daily weight is important to monitor for fluid status. Little fluctuation in weight suggests that there is no fluid retention and the intake is equal to output. Exudative loss of albumin occurs in burns, causing a decrease in colloid osmotic pressure. The normal serum albumin is 3.5 to 5 g/dL (35 to 50 g/L).

What should the nurse assess the client for during the early phase of burn care? A Hyponatremia B Metabolic alkalosis C Hyperkalemia D Hypernatremia

Correct Answer: Hyperkalemia Explanation: Immediately after a burn, excessive potassium from cell destruction is released into the extracellular fluid. Hyponatremia is a common electrolyte imbalance in the burn client that occurs within the first week after being burned. Metabolic acidosis usually occurs as a result of the loss of sodium bicarbonate.

4. Select the patient below who is at MOST risk for complications following a burn: A. A 42 year old male with partial-thickness burns on the front of the right and left arms and legs. B. A 25 year old female with partial-thickness burns on the front of the head and neck and front and back of the torso. C. A 36 year old male with full-thickness burns on the front of the left arm. D. A 10 year old with superficial burns on the right leg.

The answer is B. When thinking about which patient will have the MOST complications following a burn think about: percentage of the total body surface area that is burned (use the rule of nine to calculate), depth of the burn, age, location of the burn, and patient's medical history. The patient in option B has 40.5% TSBA burned (option A 27%, C: 4.5%, D: 9%). Remember that the higher the total of the body surface area that is burned the higher the risk of complications due to an increase in capillary permeability (swelling, hypovolemic shock etc.). In addition, the location of the burn is a major issue with the patient in option B. The burns are on the head and neck and front and back of the torso. Therefore, with head and neck burns always think about respiratory issues because the airway can become compromised due to swelling or an inhalation injury. And with torso burns that are on the front and back, the patient is at risk for circumferential burns that can lead to further respiratory compromise. The other options have burns that are isolated.

9. A 30 year old female patient has deep partial thickness burns on the front and back of the right and left leg, front of right arm, and anterior trunk. The patient weighs 63 kg. Use the Parkland Burn Formula: What is the flow rate during the FIRST 8 hours (mL/hr) based on the total you calculated? A. 921 mL/hr B. 938 mL/hr C. 158 mL/hr D. 789 mL/hr

The answer is A: 921 mL/hr....First calculate the total amount of fluid needed with the formula: Total Amount of LR = 4 mL x BSA % x pt's weight in kg. The pt's weight 63 kg. BSA percentage: 58.5%...Front and back of right and left leg (36%), front of right arm (4.5%), anterior trunk (18%) which equals 58.5%. ......4 x 58.5 x 63 = 14,742 mL......Remember during the FIRST 8 hours 1/2 of the solution is infused, which will be 14,742 divided by 2 = 7371 mL......Hourly Rate: 7371 divide by 8 equals 921 mL/hr

17. A patient experienced a full-thickness burn 72 hours ago. The patient's vital signs are within normal limits and urinary output is 50 mL/hr. This is known as what phase of burn management? A. Emergent B. Acute C. Rehabilitative

The answer is B. This phase starts when capillary permeability has returned to normal and the patient's vitals are within normal limits and ends with wound closure. The phase after this is rehabilitative.

A school-age child has just spilled hot liquid on his arm, and a 4-inch (10-cm) area on his forearm is severely burned. His mother calls the emergency department. What should the nurse advise the mother to do? A Keep the child warm. B Call 911 to transport the child to the hospital. C Cover the burned area with an antibiotic cream. D Apply cool water to the burned area.

Correct Answer: Apply cool water to the burned area. Explanation: To prevent further injury to the skin, the mother should apply cool water to the burn site. Doing so causes vasoconstriction, retards further damage to tissues, and decreases fluid loss. Keeping the child warm promotes vasodilation, increases fluid loss, and decreases blood pressure and, thus, circulation to the area. Applying ointment to the burn is contraindicated because it does not allow healing to occur and may need to be removed in the hospital. Only a clean cloth should be used to cover the wound to prevent contamination or decrease pain or chilling. If only the arm is burned, a call to 911 for emergency care is not necessary, but the mother should seek health care services immediately.

A client is admitted to the emergency department with partial-thickness burns on the scalp, chest, and neck. The client's blood pressure is 96/62 with a heart rate of 86 beats per minute. The nurse notes that the client's voice is slightly hoarse. Which intervention should the nurse implement first? A Cleanse the skin with sterile saline to prevent infection. B Hang a saline infusion wide open to keep the BP normal. C Notify the healthcare provider and prepare to intubate the client. D Observe the client for evidence of distress.

Correct Answer: Notify the healthcare provider and prepare to intubate the client. Explanation: Clients with burns around the face are at increased risk of an inhalation injury. The edema that results can be sudden and occlude the airway almost immediately. Most burn centers intubate immediately when the risk of inhalation injury is present. The client has a low normal blood pressure and normal heart rate at present. The massive fluid shifts will happen imminently, but maintaining the airway first is the top priority. The skin should be cleaned to prevent infection but this clearly is not the priority. Observing for distress is not the priority for this injury.

Which factor would have the least influence on the survival and effectiveness of a burn victim's porcine grafts? A Immobilization of the area being grafted B Adequate vascularization in the grafted area C Use of analgesics as necessary for pain relief D Absence of infection in the wounds

Correct Answer: Use of analgesics as necessary for pain relief Explanation: Analgesic administration to keep a burn victim comfortable is important but is unlikely to influence graft survival and effectiveness. Absence of infection, adequate vascularization, and immobilization of the grafted area promote an effective graft.

The nurse uses the "rule of nines" to calculate the client's percentage of burns according to total body surface area (TBSA). What percentage of TBSA burns should the nurse record for this client?

Correct Answers: 36% 36 % Explanation: When using the Rule of Nines the body is divided into surface areas that are divisible by 9. Each side of a leg is 9% and each side of the torso is 18%. This client has both posterior sides of the legs (9% + 9%) and one side of the torso (18%), for a total of 36% burns.