Burns

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, the nurse calls the health care provider (HCP) with a recommendation for:

IV rate increase 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.

A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion?

Scale, is the characteristic secondary lesion occurring in psoriasis. Although crusts, ulcers, and scars also are secondary lesions in skin disorders, they don't occur with psoriasis

Following a small-bowel resection, a client develops fever and anemia. The surface surrounding the surgical wound is warm to the touch and necrotizing fasciitis is suspected. Another manifestation that suggests necrotizing fasciitis is:

Severe pressurelike pain out of proportion to visible signs distinguishes necrotizing fasciitis from cellulitis. Erythema, leukocytosis, and swelling are present in both cellulitis and necrotizing fasciitis.

While caring for the client with a burn injury who is experiencing hypersecretion of gastric acid, the nurse should observe the client for:

gastrointestinal ulceration, also known as Curling's ulcer, occurs in about half of clients suffering from severe burns. The ulceration is proportional to the extent of the burns and due to hypersecretion of gastric acid and compromised gastrointestinal perfusion.

During a routine examination of a client's fingernails, the nurse notes a horizontal depression in each nail plate. When documenting this finding, the nurse should use which term?

Beau's line. Beau's line is a horizontal depression in the nail plate. Occurring alone or in multiples, these depressions result from a temporary disturbance in nail growth. A splinter hemorrhage is a linear red or brown streak in the nail bed. Paronychia refers to an inflammation of the skinfold at the nail margin. Clubbing describes an increased angle between the nail plate and nail base.

During the emergent stage of burn management for a client with burns of 30 percent of the body the nurse should assess the client for which of the following? Select all that apply.

Hyperkalemia. • Increased hematocrit. • "Fever spikes." Explanation: In the emergent phase of burn management, hyperkalemia develops as a result of the destruction of red blood cells. The hematocrit is increased d/t plasma loss and hemoconcentration. Initially, hyponatremia results from sodium shifts into interstitial spaces. "Fever spikes" of 102 to 103 degrees F (38.9 to 39.4 degrees C) are common during this stage. The client will have hyperglycemia due to decreased levels of insulin production.