Chapter 62: Management of Patients with Burn Injury

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

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Fluid and Electrolyte Alterations, p. 1851.

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

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.

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

27% Explanation: The TBSA would be 27%. That is 18% of the body surface for the anterior trunk and 9% for the left arm. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Rule of Nines, p. 1848.

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? Apply warm compresses over the areas. Instruct to pat and not scratch the areas. Elevate the extremities above heart level. Provide pain medication as needed.

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.

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

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Chart 62-5, p. 1855.

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

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Table 62-1, p. 1847.

When using the Palmer method to estimate the extent of a small or scattered burn injury, the nurse recognizes the palm is equal to which percentage of total body surface area? 1 2 3 4

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1849.

The palm represents which percentage of a person's TBSA? 1% 5% 10% 15%

1% Explanation: A quick assessment technique is to compare the client's palm with the size of the burn wound. The palm is approximately 1% of a person's TBSA. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Palmer Method, p. 1849.

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: Reddened; blanches with pressure. Blistered with a mottled red base. Dry and pale white. 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Table 62-1, p. 1847.

Which of the following is the preferred IV fluid for burn resuscitation? Lactated Ringer's (LR) Normal saline (NS) D5W Total parenteral nutrition (TPN)

Lactated Ringer's (LR) Explanation: LR is the preferred IV fluid for burn resuscitation because the sodium concentration and potassium are similar to normal intravascular levels. NS, D5W, and TPN are not the IV of choice for burn resuscitation. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Medical Management, p. 1854.

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which IV fluid does the nurse plan to administer first? Albumin Dextrose 5% in water (D5W) Lactated Ringer's solution Normal saline solution with 20 mEq of potassium per 1,000 ml

Lactated Ringer's solution Explanation: Lactated Ringer's solution replaces lost sodium and corrects metabolic acidosis, both of which commonly occur following a burn. Albumin is used as adjunct therapy, not as primary fluid replacement. D5W isn't given to burn clients during the first 24 hours because it can cause pseudodiabetes. The client is hyperkalemic as a result of the potassium shift from the intracellular space to the plasma, so giving potassium would be detrimental. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Medical Management, p. 1854.

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

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Biosynthetic and Synthetic Dressings, p. 1864.

The nurse recognizes the first dressing change at the site of an autograft is performed 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 sanguineous drainage is noted.

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1864.

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 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 an expensive sheet of skin obtained from a culture."

"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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1864.

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 Gentamicin sulfate Sulfadiazine, silver (Silvadene) Mafenide (Sulfamylon)

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.)

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? Superficial Full-thickness Superficial partial-thickness Deep partial-thickness

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Table 62-1, p. 1847.

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

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Prevention and Treatment of Scars, p. 1869.

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

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Nursing Management, p. 1856.

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

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Table 62-4, p. 1862.

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: stasis. coagulation. hyperemia. 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1849.

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

tetracycline Explanation: Silver sulfadiazine (Silvadene), mafenide (Sulfamylon), and silver nitrate (AgNO3) 0.5% solution are the three major antimicrobials used to treat burns. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1862.

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? escharotomy debridement allograft silvadene application

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1851.

A client who was severely burned begins to exhibit symptoms of renal failure during treatment. What physiologic process can cause acute renal failure? hemoconcentration anemia fluid, electrolyte status histamine

hemoconcentration Explanation: The client with a burn experiences hemoconcentration when the plasma component of blood is lost or trapped. Myoglobin and hemoglobin are transported to the kidneys, where they may cause tubular necrosis and acute renal failure. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1852.

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

inflammatory Explanation: The initial burn injury is further extended by inflammatory processes that affect layers of tissue below the initial surface injury. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1850.

Acticoat antimicrobial barrier dressings used in the treatment of burn wounds can be left in place for which time frame? 7 to 10 days 3 days 5 days 2 days

5 days Explanation: Acticoat antimicrobial barrier dressings can be left in place for up to 5 days thus helping to decrease discomfort to the client, decrease costs of dressing supplies, and decrease nursing time involved in burn dressing changes. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1861.

As the first priority of care, a patient with a burn injury will initially need: a patent airway established. an indwelling catheter inserted. fluids replaced. 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, On-the-Scene Care, p. 1853.

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? allograft xenograft autograft slit graft

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1864.

Specific potential complications are common to specific types of burns. Which burns can impair ventilation? face, neck, chest perineal hands, major joints legs

face, neck, chest Explanation: Burns of the face, neck, or chest have the potential to impair ventilation due to their proximity to the areas where breathing occurs.

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 victims suffering from thermal burns?" "How many victims are anticipated for transport?" "Are the burns associated with chemicals used in the plant?" "Are any of the victims expected to have electrical 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, On-the-Scene Care, p. 1853.

A client is cared for in a burn unit after suffering partial-thickness burns. The client's laboratory work reveals a positive wound culture for gram-negative bacteria. The health care provider orders silver sulfadiazine to be applied to the client's burns. The nurse provides information to the client about the medication. Which statement made by the client indicates an understanding about this treatment? Select all that apply. "This medication is an antibacterial." "This medication will be applied directly to the wound." "This medication will stain my skin permanently." "This medication will help my burn heal."

"This medication is an antibacterial." "This medication will be applied directly to the wound." "This medication will help my burn heal." This medication is an antibacterial, which has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. This medication is directly applied to the wound. This medication will not stain the client's skin, but it will help heal the client's burned areas. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Table 62-4, p. 1862.

A client is cared for in a burn unit after suffering partial-thickness burns. The client's laboratory work reveals a positive wound culture for gram-negative bacteria. The health care provider orders silver sulfadiazine to be applied to the client's burns. The nurse provides information to the client about the medication. Which statement made by the client indicates an understanding about this treatment? Select all that apply. "This medication is an antibacterial." "This medication will be applied directly to the wound." "This medication will stain my skin permanently." "This medication will help my burn heal."

"This medication is an antibacterial." "This medication will be applied directly to the wound." "This medication will help my burn heal." This medication is an antibacterial, which has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. This medication is directly applied to the wound. This medication will not stain the client's skin, but it will help heal the client's burned areas. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Table 62-4, p. 1862.

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? 1 2 3 4

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1849.

A client presents to the emergency department following a burn injury. The client has burns to the abdomen and front of the left leg. Using the rule of nines, the nurse documents the total body surface area percentage as 36%. 27%. 18%. 9%.

18%. Explanation: The rule-of-nines system is based on dividing anatomic regions, each representing approximately 9% of the total body surface area (TBSA), quickly allowing clinicians to obtain an estimate. If a portion of an anatomic area is burned, the TBSA is calculated accordingly—for example, if approximately half of the anterior leg is burned, the TBSA burned would be 4.5%. More specifically, with an adult who has been burned, the percent of the body involved can be calculated as follows: head = 9%, chest (front) = 9%, abdomen (front) = 9%, upper/mid/low back and buttocks = 18%, each arm = 9% (front = 4.5%, back = 4.5%), groin = 1%, and each leg = 18% total (front = 9%, back = 9%). In this case the client's abdomen (9%) and front of the left leg (9%) add up to 18%. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1848.

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? 1,200 mL 2,400 mL 3,600 mL 4,800 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Medical Management, p. 1854.

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? 18% 27% 30% 36%

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Rule of Nines, p. 1848.

The nurse provides care for a client with a full-thickness, circumferential burn of the left lower leg. During the nurse's initial shift assessment, the client is resting and the physical assessment of the left lower extremity is unremarkable. One hour later, the nurse notes the pulses of the left lower leg cannot be obtained by a Doppler ultrasound device, and the capillary refill of the left great toe is greater than 2 seconds. What is the nurse's best response based on the clinical findings? Elevate the leg on pillows and reassess the leg in 1 hour. Document the findings and instruct the client to report numbness of the extremity. Contact the primary care provider and prepare for an escharotomy. Apply an elastic stocking to the extremity and administer SQ heparin per order.

Contact the primary care provider and prepare for an escharotomy. Explanation: The nurse assesses peripheral pulses frequently with a Doppler ultrasound device, if needed. Frequent assessment also includes warmth, capillary refill, sensation, and movement of extremity. It is necessary for the nurse to report loss of pulse or sensation or presence of pain to the physician immediately and to prepare to assist with an escharotomy. The other interventions are inappropriate when the nurse has detected a loss of peripheral pulses. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1851.

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? Hypernatremia Hypokalemia Hyperkalemia Hypercalcemia

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Fluid and Electrolyte Alterations, p. 1851.

The nurse receives a client following a serious thermal burn. Which complication will the nurse take action to prevent first? Tissue hypoxia Infection Renal failure 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Cardiovascular Alterations, p. 1850.

A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene? Do nothing until the chemical agent is identified. Irrigate the wounds with water. Wash the wounds with soap and water and apply a barrier cream. Insert a 20-gauge I.V. catheter and infuse normal saline solution at 150 ml/hour.

Irrigate the wounds with water. Explanation: The nurse should begin treatment by irrigating the wounds with water. Delaying treatment until the agent is identified allows the agent to cause further tissue damage. Washing the wounds with soap and water might cause a chemical reaction that may further damage tissue. The client may require I.V. fluid; however, the wounds should be irrigated first. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Chart 62-4, p. 1854.

Which of the following is the effect of protein catabolism in a client with severe burns? It compromises wound healing and immunocompetence. It compromises dexterity and mobility. It maximizes the risk of sodium retention and hypotension. It maximizes the risk of impaired ventilation.

It compromises wound healing and immunocompetence. Explanation: Protein catabolism in a client with severe burns compromises wound healing and immunocompetence. Burns of the face, neck, or chest have the potential to impair ventilation, while burns involving the hands or major joints may affect dexterity and mobility. Release of aldosterone, not protein catabolism, causes sodium retention. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Modulation of Hypermetabolism, p. 1865.

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. Music therapy diverts the client's attention toward painful stimulus. Humor therapy has not proven effective in the management of burn pain. Pet therapy has proven effective in the management of burn pain.

Music therapy may provide reality orientation, distraction, and sensory stimulation. Explanation: Researchers have found that music affects both the physiologic and psychological aspects of the pain experience. Music diverts the client's attention away from the painful stimulus. Music may also provide reality orientation, distraction, and sensory stimulation. It allows for client self-expression. Humor therapy has proven effective in the management of burn pain. Pet therapy has not proven effective in the management of burn pain. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1865.

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? Face only Face, neck, and chest Face and neck Neck and chest

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Wound Grafting, p. 1863.

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? Presence of soot around nasal passages Fracture of the fibula with displacement Elevation of blood pressure and heart rate 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Acute Respiratory Failure and Acute Respiratory Distress Syndrome, p. 1867.

A nurse is providing discharge teaching for a client with a burn wound on the leg. What instructions are important to give the client? Select all that apply. Report increased redness and wound drainage to the healthcare provider. Apply lubricating lotion to the wound bed. Wash the wound with soap and water. Continue physical therapy exercises. Take pain medications daily.

Report increased redness and wound drainage to the healthcare provider. Wash the wound with soap and water. Continue physical therapy exercises. The client being discharged with burn wound care needs to demonstrate wound care technique; take prescribed pain medications if needed 30 minutes prior to wound care to achieve maximum effectiveness; use mild soap, water, and a clean washcloth to clean wounds; apply prescribed topical medications( not lubricating lotions to the wound bed) and dressings as instructed; inspect wounds carefully with each dressing change for signs of infection, including increased redness, swelling, drainage, or foul odor; and state aspects of activities of daily living as per therapy. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1871.

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 Acute Pain Infection Risk Altered Tissue Perfusion

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, On-the-Scene Care, p. 1853.

The client is admitted with full-thickness burns to the forearm. Which is the most accurate interpretation made by the nurse? The wound will take up to 3 weeks to heal. Pain management will be a challenge. Skin grafting will be necessary. Ligaments, tendons, muscles, and bone are not involved.

Skin grafting will be necessary. Explanation: In a full-thickness burn, all layers of the skin are destroyed and will result in the need for skin grafts. Full-thickness burns are painless. A deep partial-thickness burn may take 3 or more weeks to heal. In the most serious full-thickness burns, ligaments, tendons, muscles, and bone may be involved. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Table 62-1: Characteristics of Burns According to Depth, p. 1847.

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

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Table 62-1, p. 1847.

When the area of burn is irregular in shape and is scattered over multiple areas of the body, which is the best method for the nurse to obtain a quick assessment of the total body surface area of the burn? Rule of nines Use client's palm size Parkland formula Lund and Browder burns assessment

Use client's palm size Explanation: A quick assessment technique to use to evaluate an area of burn that is not restricted to one portion of the body is by using the client's palm size to approximate the total body surface. The palm is approximately 1% of a person's TBSA. The Parkland formula determines fluid resuscitation needs. Lund and Browder burns assessment provides a more precise estimate for determining TBSA that is burned and is especially more specific in children. The rule of nines quantitates burns that involve entire sections of the body, not scattered burns. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Palmer Method, p. 1849.

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 metabolic rate. increased glucose demands. increased skeletal muscle breakdown. 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1865.

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. What depth of burn injury does the client have? full thickness (third degree) superficial (first degree) superficial partial-thickness or deep partial-thickness (second degree) fourth 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1848.

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? "Perhaps the garment should be resized." "The garment acts as a skin layer and prevents infection." "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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Prevention and Treatment of Scars, p. 1869.

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." "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 encourages your body's natural processes to liquefy any damaged tissue."

"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.

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? 1,200 mL 2,400 mL 3,600 mL 4,800 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Medical Management, p. 1854.

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? 9% 18% 27% 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Rule of Nines, p. 1848.

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

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1849.

When the nurse learns that the client suffered injury from a flash flame, the nurse anticipates which depth of burn? Deep partial thickness Superficial partial thickness Full thickness Superficial

Deep partial thickness Explanation: A deep, partial-thickness burn is similar to a second-degree burn and is associated with scalds and flash flames. Superficial partial thickness burns are similar to first-degree burns and are associated with sunburns. Full thickness burns are similar to third-degree burns and are associated with direct flame, electric current, and chemical contact. Injury from a flash flame is not associated with a burn that is limited to the epidermis. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Table 62-1, p. 1847.

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? Full-thickness Superficial Superficial partial-thickness Deep partial-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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Burn Depth, p. 1848.

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. 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. 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. 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Chart 62-4, p. 1854.

The nurse cares for a client with extensive burn injuries. Which parameter(s) would the nurse evaluate to determine if the client is receiving adequate fluid resuscitation? Select all that apply. Blood pressure Heart rate Urine output Oxygen saturation

Heart rate Urine output Fluid resuscitation is administered to maintain adequate cardiac output and tissue perfusion. If adequate fluid is administered, tachycardia, hypotension, and oliguria will resolve. Expected outcomes of fluid resuscitation specifically include the following: urine output between 0.5 and 1.0 mL/kg/hr (30-50 mL/hr; 75 to 100 mL/hr if electrical burn injury), mean arterial pressure (MAP) pressure > 60 mm Hg, voids clear yellow urine with specific gravity within normal limits, and serum electrolytes are within normal limits. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1854.

What are the expected findings in the fluid remobilization phase (acute phase, diuresis) that the nurse should monitor for? Select all that apply. Hemodilution Increased urinary output Metabolic alkalosis Sodium deficit Hypoglycemia

Hemodilution Increased urinary output Sodium deficit Hemodilution (decreased hematocrit), increased urinary output, metabolic acidosis (not alkalosis), sodium deficit, and hypokalemia (not hypoglycemia) are typical fluid and electrolyte changes that occur in the acute phase (fluid remobilization phase, state of diuresis). Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Cardiovascular Alterations, p. 1851.

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? Autografts Heterografts Homografts Xenografts

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Homografts and Xenografts, p. 1864.

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

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Fluid and Electrolyte Alterations, p. 1851.

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

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Gastrointestinal Alterations, p. 1853.

Which type of debridement occurs when nonliving tissue sloughs away from uninjured tissues? Mechanical Natural Enzymatic Surgical

Natural Explanation: Natural debridement is accomplished when nonliving tissue sloughs away from uninjured tissue. Mechanical debridement involves the use of surgical tools to separate and remove the eschar. Enzymatic debridement encompasses the use of topical enzymes to the burn wound. Surgical debridement uses the use of forceps and scissors during dressing changes or wound cleaning. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Natural Debridement, p. 1862.

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

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Quality and Safety Nursing Alert, p. 1853.

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 is in hypovolemic shock. The client has experienced extensive full-thickness burns. The paramedic administered high doses of opioids during transport. The client has experienced partial-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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Table 62-1: Characteristics of Burns According to Depth, p. 1847.

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 heart rate is rapid. The client's urinary output is 0.5 mL/kg/hour. The client's breathing is unlabored and skin is clammy. The client is conscious.

The client's urinary output is 0.5 mL/kg/hour. Explanation: Successful fluid resuscitation is gauged by a urinary output of 0.5 mL/kg/hour via an indwelling catheter. Fluid resuscitation does not directly affect the client's heart rate, breathing, or mental status. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Medical Management, p. 1854.

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 Urine output of 20 ml/hour White pulmonary secretions Rectal temperature of 100.4° F (38° C)

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Medical Management, p. 1854.

A client with deep partial-thickness and full-thickness burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse provides additional client teaching because these exercises may: dislodge the autografts. increase edema in the arms. increase the amount of scarring. decrease circulation to the fingers.

dislodge the autografts. Explanation: Because exercising the autograft sites may dislodge the grafted tissue, the nurse should advise the client to keep the grafted extremity in a neutral position. Exercise doesn't cause increased edema, increased scarring, or decreased circulation. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Care of the Graft Site, p. 1864.

The nurse cares for a client with superficial partial-thickness burn injuries to the lower extremities. The client is ordered IV morphine for pain. The nurse understands narcotics are given via IV during the initial management of pain because the client can experience nausea and emesis when given oral medications. pain resulting from a burn injury requires relief by the fastest route available. bleeding may occur at injection sites when the intramuscular route is used. tissue edema may interfere with drug absorption via other routes.

tissue edema may interfere with drug absorption via other routes. Explanation: IV administration is necessary because of altered tissue perfusion from the burn injury. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Table 62-6, p. 1858.

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 will wear sun block with the highest SPF possible to protect exposed burned skin from the sun." "I will drink a lot of fluids to prevent constipation since I am taking pain medications." "As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help." "I can work with the social worker to find funding assistance programs to help with my medical expenses."

"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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1866.

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

Hypotension Tachycardia Anxiety Tachycardia, slight hypotension, and anxiety are expected soon after the burn. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Nursing Management, p. 1856.

In a client who has been burned, which medication should the nurse expect to use to prevent infection? Lindane (Kwell) Diazepam (Valium) Mafenide (Sulfamylon) Meperidine (Demerol)

Mafenide (Sulfamylon) Explanation: The topical antibiotic mafenide is ordered to prevent infection in clients with partial-thickness and full-thickness burns. Lindane is a pediculicide used to treat lice infestation. Diazepam is an antianxiety agent that may be administered to clients with burns, but not to prevent infection. The opioid analgesic meperidine is used to help control pain in clients with burns. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Table 62-4, p. 1862.

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

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Medical Management, p. 1854.

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. infection. body image. pain management.

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Table 62-1, p. 1847.

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

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Cardiovascular Alterations, p. 1850.

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. If the clothing is on fire, the client is placed in a horizontal position and rolled in a blanket to smother the fire. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Chart 62-4, p. 1854.

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 10 mL/hr A urinary output of 30 mL/hr A urinary output of 80 mL/hr A urinary output of 100 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). Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Chart 62-6, p. 1857.

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 A weight gain of 4 lb (2 kg) in 24 hours Body temperature readings all within normal limits An electrocardiogram (ECG) showing no arrhythmias

A urine output consistently above 40 ml/hour Explanation: In a client with burns, the goal of fluid resuscitation is to maintain a mean arterial blood pressure that provides adequate perfusion of vital structures. If the kidneys are adequately perfused, they will produce an acceptable urine output of at least 0.5 ml/kg/hour. Thus, the expected urine output of a 155-lb client is 35 ml/hour, and a urine output consistently above 40 ml/hour is adequate. Weight gain from fluid resuscitation isn't a goal. In fact, a 4-lb weight gain in 24 hours suggests third spacing. Body temperature readings and ECG interpretations may demonstrate secondary benefits of fluid resuscitation but aren't primary indicators. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Medical Management, p. 1854.

A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client? Anemia Gastric ulcers Hyperthyroidism Cardiac arrest

Gastric ulcers Explanation: The release of histamine as a consequence of the stress response increases gastric acidity. The client with a burn is prone to develop gastric (Curling's) ulcers. Anemia develops because of the heat destroying the erythrocytes. Release of histamine does not cause hyperthyroidism or cardiac arrest. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Gastrointestinal Alterations, pp. 1852-1853.

Which of the following measures can be used to cool a burn? Application of cool water Application of ice directly to burn Wrapping the person in ice 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Chart 62-4, p. 1854.

In a client with burns on the legs, which nursing intervention helps prevent contractures? Applying knee splints Elevating the foot of the bed Hyperextending the client's palms Performing shoulder range-of-motion exercises

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Promoting Physical Mobility, pp. 1866-1867.

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 K+: 5.0 mEq/L Na+: 145 mEq/L Ca: 9 mg/dL

BUN: 28 mg/dL Explanation: The elevated BUN would cause the nurse the most concern. The nurse should report decreased urine output or increased BUN and creatinine values to the physician. These laboratory values indicate possible renal failure. In addition, myoglobinuria, associated with electrical burns, is common with muscle damage and may also cause kidney failure if not treated. The other values are within normal limits.

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1849.

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? Superficial partial thickness Deep partial-thickness Full-thickness Fourth degree

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.

The nurse recognize what as an early sign of sepsis in a client with a burn injury? Normal body temperature Decreased heart rate Elevated serum glucose Widened pulse pressure

Elevated serum glucose Explanation: In clients with burn injuries early sepsis can be hard to detect. Clients with burn injuries exhibit tachycardia, tachypnea, and elevated body temperature, all typical indications of sepsis. In the client with burn injury, indications of sepsis include elevated serum glucose values, increased heart rate, and narrowing mean arterial pressure. Both the typical elevated temperature and a temperature of less than 96.8 F (36 C) can indicate sepsis in a client with a burn injury.

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: Epidermal layer only. Epidermis and a portion of deeper dermis. Entire dermis and subcutaneous tissue. Dermis and connective 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Table 62-1, p. 1847.

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately? Complaints of intense thirst Moderate to severe pain Urine output of 70 ml the first hour 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Chart 62-6, p. 1857.

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

Hourly urine output Daily weights Skin turgor 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Restoring Normal Fluid Balance, p. 1866.

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

Intravenous Explanation: Intravenous administration is necessary because of altered tissue perfusion from burn injury. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Chart 62-6, p. 1858.

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 Hematemesis Paralytic ileus Ulcerative colitis

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Gastrointestinal Alterations, p. 1853.

Which of the following is a true statement regarding the purposes of skin grafts? Increases evaporative fluid loss. Increases potential for infection. Reduces scarring and contractures. Prolongs recovery

Reduces scarring and contractures. Explanation: Purposes of a skin graft include the reduction of scarring and contractures, to decrease evaporative fluid loss, decrease the potential for infection, and speed recovery. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Wound Grafting, p. 1863.

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

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Chart 62-4, p. 1854.

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? It helps determine the percentage of the total body surface area (TBSA) that is burned. The client's condition is likely to deteriorate after 72 hours. The wound is susceptible to infections. The early appearance of the burn injury may change.

The early appearance of the burn injury may change. Explanation: The nurse is required to reassess and revise the estimate of burn depth because the early appearance of the burn injury may change. Assessing the burn depth helps determine the potential of the damaged tissue to survive. It does not establish the percentage of the TBSA that is burned or minimize the risk of infections. It also does not help determine whether the client's condition is likely to deteriorate after 72 hours. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Lund and Browder Method, p. 1849.

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 glucose demands. increase skeletal muscle breakdown. 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1865.