Chapter 57 PrepU: Management of Patients with Burn Injury

The nurse determines which statement reflects current research regarding the utilization of nonpharmacological measures in the management of burn pain?

Music therapy may provide reality orientation, distraction, and sensory stimulation.

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

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?

36%

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 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.

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?"

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?

"As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help."

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 reduces the risk of complications from an infection."

In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client?

A urine output consistently above 40 ml/hour

Initial first aid rendered at the scene of a fire includes preventing further injury through heat exposure. Which intervention could contribute to tissue hypoxia and necrosis and therefore should be avoided?

Application of ice

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

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.

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

Fluid resuscitation

Following a burn injury, the nurse determines which area is the priority for nursing assessment?

Pulmonary system

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?

Sulfadiazine, silver (Silvadene)

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 extensive full-thickness burns.

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's urinary output is 0.5 to 1 mL/kg/hour.

A client receiving emergency treatment for severe burns has just been assessed to establish the burn depth. Why is a nurse asked to reassess the burn depth after 72 hours?

The early appearance of the burn injury may change.

A client who has been burned significantly is taken by air ambulance to the burn unit. What physiologic process furthers a burn injury?

inflammatory

A client who was severely burned begins to exhibit symptoms of renal failure during treatment. What physiologic process can cause acute renal failure?

hemoconcentration

Which antimicrobials is not commonly used to treat burns?

tetracycline

Skin grafts are necessary for what type of burn?

Full-thickness

Which of the following is the effect of protein catabolism in a client with severe burns?

It compromises wound healing and immunocompetence.

Which of the following is the preferred IV fluid for burn resuscitation?

Lactated Ringer's (LR)

The nurse recognizes that which of the following provide clues about fluid volume status? Select all that apply.

-Hourly urine output -Daily weights -Skin turgor

Which of the following is to be expected soon after a major burn? Select all that apply.

-Hypotension -Tachycardia -Anxiety

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.

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?

2,400 mL

A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned?

27%

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%

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%

A client is brought to the emergency department by a coworker following a burn injury from a high-voltage electrical power line. The triage nurse determines which intervention should be completed first?

Apply a cervical collar on the client

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

Applying knee splints

A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern?

BUN: 28 mg/dL

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

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?

Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel.

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately?

Hoarseness of the voice

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?

Hyperkalemia

Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is:

Hyperkalemia.

A child tips a pot of boiling water onto his bare legs. The mother should:

Immerse the child's legs in cool water.

Which zone of burn injury sustains the most damage?

Inner

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?

Instruct to pat and not scratch the areas.

Which of the following is the analgesic of choice for burn pain?

Morphine sulfate

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?

Preexisting conditions

Which of the following fluid or electrolyte changes occur in the emergent/resuscitative phase?

Reduction in blood volume

A nurse formulates a nursing diagnosis of Impaired physical mobility for a client with full-thickness burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase?

Related to circumferential eschar

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?

Risk for Impaired Gas Exchange

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?

Roll the client in a blanket.

Which of the following topical burn preparations act as wick for sodium and potassium?

Silver nitrate solution

The client is admitted with full-thickness burns to the forearm. Which is the most accurate interpretation made by the nurse?

Skin grafting will be necessary.

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

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?

full thickness (third degree)

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.

A client has received significant electrical burns in a workplace accident. What occurrence makes it difficult to assess internal burn damage in electrical burns?

deep tissue cooling