Burns

The nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing grad planned to implement which unsafe component of protective isolation technique? A. Using sterile sheets and linens B. Performing strict hand-washing technique C. Wearing gloves and a gown only when giving direct care to the pt D. Wearing protective garb, including a mask, gloves, cap, shoe covers, gowns, and plastic apron

C. Wearing gloves and a gown only when giving direct care to the pt

After the initial phase of the burn injury, the pt's plan of care will focus primarily on: A. helping the pt maintain a positive self-concept B. promoting hygiene C. preventing infection D. educating the pt regarding care of the skin grafts

C. preventing infection

A pt arrives at the ER following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the pt? 1. 100% o2 via an aerosal mask 2. O2 via nasal cannula at 6L/min 3. o2 via nasal cannula at 15L/min 4. 100% o2 via a tight-fitting, nonrebreather face mask

4. 100% o2 via a tight-fitting, nonrebreather face mask

There has been a fire in an apartment building. All the residents have been evacuated, but many are burned. Which pts should be transported to a burn center for treatment? SA A. An 8yo with third degree burns over 10% of the BSA B. A 20 yo who inhaled the smoke of the fire C. A 50 yo diabetic with first and second degree burns on the left forearm (about 5% BSA) D. A 30 yo with 2nd degree burns on the back of the left leg (about 9% of BSA) E. a 40 yo with second-degree burns on the right arm (about 10% BSA)

A. An 8yo with third degree burns over 10% of the BSA; under 10 B. A 20 yo who inhaled the smoke of the fire C. A 50 yo diabetic with first and second degree burns on the left forearm (about 5% BSA); 50 & older; chronic disease

A nurse is assessing a pt who sustained deep partial-thickness and full-thickness burns over 40% if his body 24 hr ago. Which of the following are findings should the nurse expect? SA A. Dyspnea B. Bradycardia C. Hyperkalemia D. Hyponatremia E. Decreased Hematocrit

A. Dyspnea C. Hyperkalemia D. Hyponatremia

A nurse is planning care for an adult client who sustained severe burn injuries. Which of the following interventions should the nurse include in the plan of care? SA A. Limit visitors in the pt's room B. Encourage fresh vegetables in the diet C. Increase protein in the diet D. Instruct the client to consume 2,000 calories/day E. Restrict fresh flowers in the room

A. Limit visitors in the pt's room: decreases risk of infection C. Increase protein in the diet E. Restrict fresh flowers in the room Incorrect: B. Encourage fresh vegetables in the diet: increases risk for infection D. Instruct the client to consume 2,000 calories/day: pt should consume up to 5,000 calories/day because caloric needs double or triple beginning 12-14 days following the burn

The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy? A. Return of distal pulses B. Brisk bleeding from the site C. Decreasing edema formation D. Formation of granulation tissue

A. Return of distal pulses: echarotomies are performed to relieve the compartment syndrome that can occur when edema forms under the nondistensible eschar in a circumferential third-degree burn.

A nurse in a provider's office is assessing a pt who has a severe sunburn. Which of the following classifications should the nurse use to document this burn? A. Superficial thickness B. Superficial partial thickness C. Deep partial thickness D. Full thickness

A. Superficial thickness

The nurse should plan to begin rehab efforts for the burn pt: A. Immediately after the burn has occurred B. After the pt's circulatory status has been stabilized C. After grafting of the burn wound has occurred D. After the pt's pain has been eliminated

B. After the pt's circulatory status has been stabilized; rehab efforts are implemented as soon as pt's condition is stabilized. Early emphasis on rehab is important to decrease complications and to help ensure that the pt 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 pt's pain; pain control is a major challenge in burn care.

A pt is brought to the ER with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this pt? SA A. Restrict fluid B. Assess airway patency C. Admin o2 as prescribed D. Place a cooling blanket E. Elevate extremties if no fractures are present F. Prepare to give PO pain meds as prescribed

B. Assess airway patency C. Admin o2 as prescribed E. Elevate extremties if no fractures are present

The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate noting which sign in the pt? A. Coma B. Flushing C. Dizziness D. Tachycardia

B. Flushing: - carbon monoxide between 11 % - 20% result in flushing, headache, decreased visual activity, decreased cerebral functioning, and slight breathlessness - levels of 21%-40% result in N/V/dizziness, titnitis, vertigo, confusion, drowsiness, pale-reddish purple skin, and tachycardia. -levels of 41% to 60% result in seizure and coma; and levels higher than 60% result in death.

In the acute phase of burn injury, which pain med would most likely be given to the pt to decrease the perception of the pain? A. PO analgesics B. IV opioids C. IM opioids D. Oral antianxiety

B. IV opioids; morphine

An advantage of using biologic burn grafts such as porcine (pigskin) grafts is that they: A. Encourage the formation of tough skin B. Promote the growth of epithelial tissue C. Provide for permanent wound closure D. Facilitate the development of subcutaneous tissue

B. Promote the growth of epithelial tissue

The nurse is administering fluids IV as prescribed to a pt who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy? A. VS B. UO C. Mental Status D. Peripheral pulses

B. UO

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

B. thermal burns to the head, face, and airway resulting in hypoxia

The rate at which IV fluids are infused is based on the burn pt's: A. lean muscle mass and body surface area (BSA) burned. B. total body weight and BSA burned C. total BSA and BSA burned D. height and weight and BSA burned

B. total body weight and BSA burned

An adult pt was burned in an explosion. The burn initially affected the pt's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The pt's clothes caught on fire, and the pt ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury? A. 18% B. 24% C. 36% D. 48%

C. 36%

A pt is receiving fluid replacement with lactated Ringer's after 40% of the body was burned 10 hours ago. The assessment reveals temp 97.1 F, HR 122, BP 84/42, CVP 2, UO 25 for the last 2 hours. The IV rate is currently is 375ml/h. Using the SBAR, the nurse calls the HCP with a recommendation for: A. Furosemide B. Fresh frozen plasma C. IV rate increase D. dextrose 5%

C. IV rate increase

The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the pt? A. OOB activities B. Bathroom privileges C. Immobilization of the affected leg D. Placing the affected leg in a dependent position

C. Immobilization of the affected leg for 3-7 days

A pt is undergoing fluid replacement after being burned on 20% of her body 12 hrs ago. The nursing assessment reveals a bp of 90/50, pulse of 110, UO 20 ml over the past hour. The nurse reports the findings to the HCP and anticipates which prescriptions? A. Transfusing 1 unit of packed RBCs B. Admin a diuretics to increase UO C. Increasing the amt of IV lactated Ringer's solution adm per hour D. Changing the IC lactated Ringer's sol to one that contains 5% dextrose in water.

C. Increasing the amt of IV lactated Ringer's solution adm per hour

A nurse is caring for a client who has sustained burns over 35% of his total body surface area. Of this total, 20% are full thickness burns on arms, face, neck and shoulders. The pt's voice has become hoarse. He has a brassy cough and is drooling. The nurse should identify these findings as indications that the pt has which of the following? A. Pulmonary edema B. Bacterial pneumonia C. Inhalation injury D. Carbon monoxide poisoning.

C. Inhalation injury

A nurse is preparing to administer fentanyl to a pt who sustained deep partial-thickness and full-thickness burn over 60% of his body 24 hour ago. The nurse should plant to use which of the following routes to administer the meds? A. Subcutaneous B. Oral C. Intravenous D. Transdermal

C. Intravenous: rapid absorption & fast pain relief

The nurse is caring for a pt with severe burns who is receiving fluid resuscitation. Which finding indicates that the pt is responding to the fluid resuscitation? A. Pulse rate of 112 bpm B. BP os 94/64 C. UO of 30ml/hr D. Serum sodium of 136

C. UO of 30ml/hr

The nurse is caring for a pt who sustained superficial partial thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury? A. Decreased HR B. Increased UO C. Increased BP D. Elevated HCT levels

D. Elevated HCT levels increases because of hemoconcentration from the large fluid shifts. HCT levels of 50% - 55% are expected during the first 24 hours after injury, with return to normal by 36 hrs after the injury.

The nurse is conducting a focused assessment of the GI system of a pt with a burn injury. The nurse should assess the pt for: A. paralytic ileus B. gastric distention C. hiatal hernia D. curling's ulcer

D. curling's ulcer, or GI ulceration, occurs in about half of the pt's 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 hypersecrection of gastric acid and compromised GI perfusion. Incorrect rationale: - paralytic ileus and gastric distention do not result from hypersecrection of gastric acid and stress and thus are not expected findings at this time. - hiatal hernia is not a complication of burn injury

During the early phase of burn care, the nurse should assess the pt for: A. hypernatremia B. hypnatremia C. metabolic alkalosis D. hyperkalemia

D. hyperkalemia: immediately after a burn, excessive potassium from cell destruction is released into the extracellular fluid. Incorrect: - hyponatremia is a common finding in the burn pt that occurs within the first week after being burned. - Metabolic acidosis occurs bc of loss of sodium bicarb