Management of Patients with Burn Injury- ch. 57

Airway management.

A client is brought to the ED by paramedics, who report that the client has partial-thickness burns on the chest and legs. The client has also suffered smoke inhalation. What is the priority in the care of a client who has been burned and suffered smoke inhalation?

Full thickness

A client is brought to the ED from the site of a chemical fire, where the client suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the client's arm?

Hemodynamic instability.

A client is brought to the ED with a burn injury. The nurse knows that the first systemic event after a minor burn injury is what event?

-Promote truthful communication. -Teach the client coping strategies. -Provide positive reinforcement.

A client is in the active phase of a burn injury. One of the nursing diagnoses in the plan of care is Ineffective Coping Related to Trauma of Burn Injury. What interventions appropriately address this diagnosis? Select all that apply.

A client-controlled analgesia (PCA) system.

A client who is in the acute phase of recovery from a burn injury has yet to experience adequate pain control. What pain management strategy is most likely to meet this client's needs?

Providing education to the client and family.

A client who was burned in a workplace accident has completed the acute phase of treatment and the plan of care has been altered to prioritize rehabilitation. What nursing action should be prioritized during this phase of treatment?

Trim away the separated xenograft.

A client with partial-thickness burn injury had a xenograft applied 2 weeks ago. The nurse notices that the xenograft is separating from the burn wound. What is the nurse's most appropriate intervention?

Decreased blood pressure.

A client with severe burns is admitted to the ICU to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the client closely for what signs of the onset of burn shock?

Lactated Ringer.

A client's burns are estimated at 36% of total body surface area; fluid resuscitation has been ordered in the ED. After establishing IV access, the nurse should anticipate the administration of what fluid?

Inform the primary care provider promptly because the graft may need to be removed.

A client's burns have required a homograft. During the nurse's most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurse's most appropriate response?

Post traumatic stress disorder

A home care nurse is performing a visit to a client's home to perform wound care following the client's hospital treatment for severe burns. While interacting with the client, the nurse should assess for evidence of what complication?

A 4-year-old scald victim burned over 24% of the body.

A nurse has reported for a shift at a busy burns and plastics unit in a large university hospital. Which client is most likely to have life-threatening complications?

Sodium deficit.

A nurse is caring for a client in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values?

Acute pain.

A nurse is caring for a client who sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis?

Prevention of venous thromboembolism.

A nurse is caring for a client with burns who is in the later stages of the acute phase of recovery. The plan of nursing care should include which of the following nursing actions?

To prevent contractures.

A nurse is developing a care plan for a client with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. What is the best rationale for this intervention?

Assess the client's psychosocial status.

A nurse is performing a home visit to a client who is recovering following a long course of inpatient treatment for burn injuries. When performing this home visit, the nurse should do which of the following?

Continuously.

A nurse is teaching a client with a partial-thickness wound how to wear the elastic pressure garment. How often should the nurse instruct the client to wear this garment?

The client is likely experiencing a delayed onset of respiratory complications.

A nurse on a burn unit is caring for a client who experienced burn injuries 2 days ago. The client is now showing signs and symptoms of airway obstruction, despite appearing stable since admitted. How should the therapist client's change in status be best understood?

"The client's body has consumed fat deposits for fuel because calorie intake is lower than normal."

A nurse who is taking care of a client with burns is asked by a family member why the client is losing so much weight. The client currently in the intermediate phase of recovery. What would be the nurse's most appropriate response to the family member?

Apply a layer of ointment approximately 1/16 inch thick.

A nurse who provides care on a burn unit is preparing to apply a client's ordered topical antibiotic ointment. What action should the nurse perform when administering this medication?

Older adults.

A public health nurse is educating a group of administrators about decreasing hospitalizations for burns. Which population will the nurse note as the target population for burn injuries?

Acute

The current phase of a client's treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the client is in what phase of burn care?

Encourage physical activity and range-of-motion exercises.

The nurse caring for a client who is recovering from full-thickness burns is aware of the client's risk for contracture and hypertrophic scarring. How can the nurse best reduce this risk?

Removal of eschar until the point of pain and bleeding occurs.

The nurse is providing education to a client that is scheduled for mechanical debridement of a wounds the nurse knows that mechanical debridement involves which element?

Immerse the child in a cool bath.

The triage nurse in the emergency department (ED) receives a phone call from a frantic parent who saw their 4-year-old child tip a pot of boiling water onto themselves. The parent has called an ambulance. What would the nurse in the ED receiving the call instruct the parent to do?

The client may be experiencing anger about current circumstances that the client is deflecting toward the nurse.

While performing a client's ordered wound care for the treatment of a burn, the client has made a series of sarcastic remarks to the nurse and criticized the nurse's technique. How should the nurse best interpret this client's behavior?

18%

A client arrives in the ED after being burned in a house fire. The client's burns cover the face and the left forearm. What extent of burns does the client most likely have, measured as a percentage?

Recognize that the client is experiencing an expected onset of diuresis.

A client experienced a 33% TBSA burn 72 hours ago. The nurse observes that the client's hourly urine output has been steadily increasing over the past 24 hours. How should the nurse best respond to this finding?

Fluid status.

A client has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurse's immediate, priority concern when planning this client's care?

Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream

A client has experienced an electrical burn and has developed thick eschar over the burn site. Which of the following topical antibacterial agents will the nurse expect the physician to order for the wound?

Assess the client's peripheral pulses distal to the dressing.

A client has experienced burns to the upper thighs and knees. Following the application of the new wound dressings, the nurse should perform which nursing action?

Hyperkalemia, hyponatremia, elevated hematocrit

A client in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the client's laboratory studies, the nurse will expect the results to indicate what findings?

Ischemia.

A client is admitted to the burn unit after being transported a long distance. The client has burns to the groin area and circumferential burns to both upper thighs. When assessing the client's legs distal to the wound site, the nurse should be cognizant of the risk of what complication?

"That's something that you and your doctor will likely talk about after your scars mature."

A burn client is transitioning from the acute phase of the injury to the rehabilitation phase. The client tells the nurse, "I can't wait to have surgery to reconstruct my face so I look like I used to." What would be the nurse's best response?

The total body surface area (TBSA) affected by the burn.

An ED nurse has just admitted a client with a burn. What characteristic of the burn will primarily determine whether the client experiences a systemic response to this injury?

Administer IV fluids.

An ED nurse has just received a client with burn injuries brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the client's body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period?

The causative agent.

An ED nurse learns from the paramedics that the team is transporting a client who has suffered injury from a scald from a hot kettle. What variables will the nurse consider when determining the depth of burn?

Wrap cool towels around the affected extremity intermittently.

An occupational health nurse is called to the floor of a factory where a worker has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to cool the burn. How should the nurse cool the burn?