Chapter 62: Management of Patients With Burn Injury
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? A. Risk for Impaired Gas Exchange B. Acute Pain C. Risk for Infection D. Alteration in Tissue Perfusion
A 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.
A patient has been prescribed Acticoat as a burn wound treatment. Which of the following is accurate regarding application of Acticoat? A. Moisten with sterile water only. B. Moisten with saline. C. Use topical antimicrobials with Acticoat burn dressing. D. Keep Acticoat saturated.
A Acticoat is moistened with sterile water only; never use normal saline. Do not use topical antimicrobials with Acticoat burn dressing. Keep Acticoat moist, not saturated.
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? A. Diverticulitis B. Hematemesis C. Paralytic ileus D. Ulcerative colitis
C 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.
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? A. Age B. Weight C. Preexisting conditions D. Family history
C Preexisting disease disorders including trauma and infections can modify the inflammatory response and movement of fluid from the vascular to the interstitial space. Age, weight, and family history are not as significant in the inflammatory response following a burn.
The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to A. increase metabolic rate. B. increase glucose demands. C. increase skeletal muscle breakdown. D. decrease catabolism.
D 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.
A patient is admitted to a burn treatment center at 2:30 p.m. with full-thickness burns over 40% of his body. The injury occurred at 1:30 p.m. at a paper-making plant. The nurse knows that burn shock has to be prevented or treated. Based on fluid volume shifts, the nurse knows that fluid loss would peak by __________ to __________ hours, with the greatest volume being lost from __________ to__________ hours after the burn. A. 7:30 p.m. to 9:30 p.m.; 24 to 36 hours B. 4:30 p.m. to 6:30 p.m.; 6 to 8 hours C. 5:30 p.m. to 6:30 p.m.; 9 to 12 hours D. 10:30 p.m. to 12:30 a.m.; 40 to 50 hours
A The greatest volume of fluid loss occurs in the first 24 to 36 hours after the burn, peaking by 6 to 8 hours.
A client who has been burned significantly is taken by air ambulance to the burn unit. What physiologic process furthers a burn injury? A. inflammatory B. neuroendocrine C. intravascular fluid excess D. hypertension
A The initial burn injury is further extended by inflammatory processes that affect layers of tissue below the initial surface injury.
A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned?
27% The TBSA would be 27%. 18% for the anterior trunk and 9% for the left arm.
Which antimicrobials is not commonly used to treat burns? A. tetracycline B. silver sulfadiazine (Silvadene) C. mafenide (Sulfamylon) D. silver nitrate (AgNO3) 0.5% solution
A
Which of the following measures can be used to cool a burn? A. Application of cool water B. Application of ice directly to burn C. Wrapping the person in ice D. Using cold soaks or dressings for at least 1 hour
A 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.
Which of the following is a potential cause of a superficial partial-thickness burn? A. Sunburn B. Scald C. Flash flame D. Electrical current
A 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.
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. A. Place the client in a horizontal position. B. Roll the client in a blanket to smother the fire. C. Place the client in a vertical position. D. Open a door and encourage air in an enclosed space.
A, B
Which of the following is to be expected soon after a major burn? Select all that apply. A. Hypotension B. Tachycardia C. Anxiety D. Hypertension E. Bradycardia
A, B, C
Which of the following is a disadvantage of surgical debridement? A. Scarring B. Bleeding C. Loss of function D. Contractures
B
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? A. Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg B. Urine output of 20 ml/hour C. White pulmonary secretions D. Rectal temperature of 100.6° F (38° C)
B 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.
Which of the following topical burn preparations act as wick for sodium and potassium? A. Silver nitrate solution B. Silver sulfadiazine (Silvadene) C. Mafenide acetate (Sulfamylon) D. Acticoat
A Silver nitrate solution is hypotonic and acts as a wick for sodium and potassium. The other preparations do not act as a wick for sodium and potassium.
Which of the following fluid or electrolyte changes occur in the emergent/resuscitative phase? A. Reduction in blood volume B. Sodium excess C. Potassium deficit D. Increased urinary output
A A reduction in blood volume occurs secondary to plasma loss. Sodium deficit, potassium excess, and decreased urinary output occurs in this phase.
Following a burn injury, the nurse determines which area is the priority for nursing assessment? A. Pulmonary system B. Cardiovascular system C. Pain D. Nutrition
A 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.
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? A. Roll the client in a blanket. B. Cover the client with a wet cloth. C. Place the client with the head positioned slightly below the rest of the body. D. Avoid immediate IV fluid therapy.
A When clothing catches fire, the flames can be extinguished if the person drops to the floor or ground and rolls ("stop, drop, and roll"); anything available to smother the flames, such as a blanket, rug, or coat, may be used. The older adult, or others with impaired mobility, could be instructed to "stop, sit, and pat" to prevent concomitant musculoskeletal injuries. 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.
The open method (exposure method) of burn care, which exposes the burned areas to air, has been virtually abandoned since the advent of effective topical antimicrobials. It is still used on a small scale however. On which areas of the body are burns still being treated this way? Select all that apply. A. The face B. The perineum C. The chest D. The legs
A, B
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: A. Epidermal layer only. B. Epidermis and a portion of deeper dermis. C. Entire dermis and subcutaneous tissue. D. Dermis and connective tissue.
B 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.
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? A. 1,200 mL B. 2,400 mL C. 3,600 mL D. 4,800 mL
B 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.
A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene? A. Do nothing until the chemical agent is identified. B. Irrigate the wounds with water. C. Wash the wounds with soap and water and apply a barrier cream. D. Insert a 20-gauge I.V. catheter and infuse normal saline solution at 150 ml/hour.
B 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.
A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client? A. Anemia B. Gastric ulcers C. Hyperthyroidism D. Cardiac arrest
B 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.
Which is the primary reason for placing a client in a horizontal position while smothering flames are present? A. To prevent collapse and further injuries B. To keep fire and smoke from airway C. To extinguish flames more quickly D. To promote blood flow to the brain and vital organs
B he 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. Stop, drop, and roll method is a quick efficient means to distinguish flames. If hypovolemic shock occurs, lowering the head will assist in promoting blood flow to the head.
Which zone of burn injury sustains the most damage? A. Outer B. Middle C. Inner D. Protective
C Each burned area has three zones of injury. The inner zone (known as the area of coagulation, where cellular death occurs) sustains the most damage. The middle area, or zone of stasis, includes a compromised blood supply, inflammation, and tissue injury. The outer zone, the zone of hyperemia, sustains the least damage.
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? A. Cerium nitrate solution B. Gentamicin sulfate C. Sulfadiazine, silver (Silvadene) D. Mafenide (Sulfamylon)
C 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.)
Which of the following is true regarding a split-thickness skin graft? A. Split thickness grafts are less successful than other types of grafts. B. Their cosmetic appearance are more desirable. C. Hair is able to grow back from their surface. D. The epidermis and a thin layer of dermis are harvested from the client's skin.
D In a split-thickness skin graft, the epidermis and a thin layer of the dermis are harvested from the client's skin. Their cosmetic appearance is less desirable. Hair does not grow back from their surface. Split thickness grafts are more successful that other types of grafts.
When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately? A. Complaints of intense thirst B. Moderate to severe pain C. Urine output of 70 ml the first hour D. Hoarseness of the voice
D 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.
A client has received significant electrical burns in a workplace accident. What occurrence makes it difficult to assess internal burn damage in electrical burns? A. deep tissue cooling B. continuing inflammatory process C. protein cell coagulation D. All options are correct.
A Because deep tissues cool more slowly than those at the surface, it is difficult initially to determine the extent of internal damage.
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% 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 thathave sustained burns to entire surfaces will equal to 36% of total surface area.
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? A. "An allograft is a temporary wound covering obtained from cadaver skin." B. "An allograft is a permanent wound covering taken from a donor site in your body." C. "An allograft is a temporary wound covering obtained from pig skin." D. "An allograft is an expensive sheet of skin obtained from a culture."
A 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.
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. A. Blood pressure B. Heart rate C. Urine output D. Oxygen saturation
A, B, C 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
The nurse recognizes that which of the following provide clues about fluid volume status? Select all that apply. A. Hourly urine output B. Daily weights C. Percentage of meals eaten D. Skin turgor E. Oxygen saturation
A, B, D 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.
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? A. Superficial partial thickness B. Deep partial-thickness C. Full-thickness D. Fourth degree
B 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.
A nurse is aware that after a burn injury and respiratory difficulties have been managed, the next most urgent need is to: A. Measure hourly urinary output. B. Replace lost fluids and electrolytes. C. Prevent renal shutdown. D. Monitor cardiac status.
B 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.
Which of the following skin substitutes is a nylon-silicone membrane coated with a protein? A. Mederma B. Integra C. Transcyte D. Biobrane
D Biobrane is a nylon-silicone membrane coated with a protein. Mederma ia 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.
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? A. It helps determine the percentage of the total body surface area (TBSA) that is burned. B. The client's condition is likely to deteriorate after 72 hours. C. The wound is susceptible to infections. D. The early appearance of the burn injury may change.
D 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.
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? A. Rule of nines B. Use client's palm size C. Parkland formula D. Lund and Browder burns assessment
B 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.
Which is the primary nursing intervention in the care of a client with burns exceeding 20% of total body surface area? A. Prevent infection B. Fluid resuscitation C. Endotracheal tube placement D. Strict intake and output
B Fluid resuscitation requirements are paramount in the management of clients having burns that exceed 20% of TBSA. Fluid resuscitation with crystalloid and colloid solutions is calculated from the time the burn injury occurred to restore the intravascular volume and prevent hypovolemic shock and renal failure. Infection prevention is a care consideration with all burns. Endotracheal tube placement may be necessary if respiratory factors indicate the need. Intake and output records are maintained to determine the success of fluid resuscitation efforts.
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? A. "I will wear sun block with the highest SPF possible to protect exposed burned skin from the sun." B. "I will drink a lot of fluids to prevent constipation since I am taking pain medications." C. "As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help." D. "I can work with the social worker to find funding assistance programs to help with my medical expenses."
C 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.
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: A. Reddened; blanches with pressure. B. Blistered with a mottled red base. C. Dry and pale white. D. Broken epidermis that is weeping.
C The wound appearance for a full-thickness burn would be dry, pale white, leathery, or charred. Refer to Table 53-1 in the text.
The nurse recognizes the first dressing change at the site of an autograft is performed A. as soon as foul odor or purulent drainage is noted, or 2 to 5 days after surgery. B. within 12 hours after surgery. C. within 24 hours after surgery. D. as soon as sanguineous drainage is noted.
A 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.
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? A. Full-thickness B. Superficial C. Superficial partial-thickness D. Deep partial-thickness
A 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 froma full-thickness burn. It is red or white, mottled, and can be moist or fairly dry.
The spouse of a client who was struck by lightning asks the nurse why the areas involved seems so small but the damage is extensive. Which is the best explanation from the nurse? A. Electrical burns usually follow an internal path. B. Lightning is higher in voltage than electricity. C. The skin is a good conductor of electricity. D. Moisture intensifies the damage inflicted.
A Electrical current follows the path of less resistance. Becausethe skin is the most resistant organ, the current follows nerves, blood vessels, and muscles, causing organ damage along the way. Lightning is high-voltage electricity. Presence of water acts as a conductor of electrical current.
A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern? A. BUN: 28 mg/dL B. K+: 5.0 mEq/L C. Na+: 145 mEq/L D. Ca: 9 mg/dL
A 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.
What are the expected findings in the fluid remobilization phase (acute phase, diuresis) that the nurse should monitor for? Select all that apply. A. Hemodilution B. Increased urinary output C. Metabolic alkalosis D. Sodium deficit E. Hypoglycemia
A, B, D 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).
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. A urinary output of 10 mL/hr B. A urinary output of 30 mL/hr C. A urinary output of 80 mL/hr D. A urinary output of 100 mL/hr
B 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).
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? A. The client is in hypovolemic shock. B. The client has experienced extensive full-thickness burns. C. The paramedic administered high doses of opioids during transport. D. The client has experienced partial-thickness burns.
B 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.
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? A. Autografts B. Heterografts C. Homografts D. Xenografts
C 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.
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: A. fluid resuscitation. B. infection. C. body image. D. pain management.
D 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.
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? A. Have someone assist him into a bath of cool water, where he can wait for emergency personnel. B. Lie down, have someone cover him with a blanket, and cover his legs with petroleum jelly. C. Remove his burned pants so that the air can help cool the wound. D. Sit in a chair, elevate his legs, and have someone cut his pants off around the burned area.
A 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.
In a client with burns on the legs, which nursing intervention helps prevent contractures? A. Applying knee splints B. Elevating the foot of the bed C. Hyperextending the client's palms D. Performing shoulder range-of-motion exercises
A Applying knee splints prevents 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.
Burn shock is characterized by which of the following? A. Capillary leak B. Severe hypervolemia C. Organ hyperperfusion D. Elevated blood pressure (BP)
A 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.
Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is: A. Hyperkalemia. B. Hypernatremia. C. Hypocalcemia. D. Hypoglycemia.
A 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.
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? A. escharotomy B. debridement C. allograft D. silvadene application
A 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.
A client with a burn wound is prescribed mafenide acetate 5% twice daily. Nursing implications associated with this medication include A. monitoring the client for the development of respiratory acidosis. B. premedicating the client with an analgesic prior to application. C. monitoring the client's Na+ and K+ serum levels and replace as prescribed. D. protecting the bed linens and client's clothing from contact to prevent staining.
B 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.
A young child is being evaluated for an area of burn involvement. The nurse knows the most accurate method of assessing the total body surface area is through the use of which assessment tool? A. Rule of nines B. Lund and Browder method C. Hand method D. Parkland formula method
B The Lund and Browder method divides the body into smaller segments. Different percentages are assigned to body parts, depending on patient's age. For example, the adult head is equivalent to 9%,whereas the infant head is 19%. This method is more accurate when dealing with children. The rule of nines and hand method are quick assessment techniques for estimating burns. The Parkland formula incorporates fluid resuscitation requirements for burns.
A child tips a pot of boiling water onto his bare legs. The mother should: A. Avoid touching the burned skin and take the child to the nearest emergency department. B. Cover the child's legs with ice cubes secured with a towel. C. Immerse the child's legs in cool water. D. Liberally apply butter or shortening to the burned areas.
C 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.
During the recovery of an extensive burn, the client is complaining about wearing the tight-fitting custom garment. Which is the best response by the nurse? A. "Perhaps the garment should be resized." B. "The garment acts as a skin layer and prevents infection." C. "A snug fit is needed to minimize scarring and overgrowth of skin." D. "The garment can be removed for an hour each day."
C 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.
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? A. "Are the victims suffering from thermal burns?" B. "How many victims are anticipated for transport?" C. "Are the burns associated with chemicals used in the plant?" D. "Are any of the victims expected to have electrical burns?"
C 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.
The nurse recognize what as an early sign of sepsis in a client with a burn injury? A. Normal body temperature B. Decreased heart rate C. Elevated serum glucose D. Widened pulse pressure
C In clients with burn injuries early sepsis can be hard to detect. Clients with burn injuries exhibit tachycardia, tacypnea, 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 sepsi in a client with a burn injury.
