MDC 4 Module 6 Burns

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. Gastric ulcers

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 100.4° F (38° C)

b. Urine output of 20 ml/hour

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? a.1,200 mL b.2,400 mL c.3,600 mL d.4,800 mL

b.2,400 mL

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

b.27%

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.A urinary output of 30 mL/hr

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.Epidermis and a portion of deeper dermis.

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

The nurse is caring for a patient who sustained a full-thickness burn to his arm when he was scalded with boiling water. How did the nurse determine that the patient's burns are full-thickness burns? a.Classification by the appearance of blisters b.Identification by the destruction of the dermis and epidermis c.Not associated with edema formation d.Usually very painful because of exposed nerve endings

b.Identification by the destruction of the dermis and epidermis

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

b.Intravenous

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.Irrigate the wounds with water.

Which type of debridement occurs when nonliving tissue sloughs away from uninjured tissues? a.Mechanical b.Natural c.Enzymatic d.Surgical

b.Natural

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.Replace lost fluids and electrolytes.

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.The client has experienced extensive full-thickness burns.

A nurse is required to monitor the effectiveness of fluid resuscitation in a client who is being treated for burns. Which of the following assessments would indicate the success of the fluid resuscitation? a.The client's heart rate is rapid. b.The client's urinary output is 0.5 mL/kg/hour. c.The client's breathing is unlabored and skin is clammy. d.The client is conscious.

b.The client's urinary output is 0.5 mL/kg/hour.

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. "An allograft is a temporary wound covering obtained from cadaver skin."

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. Hourly urine output b. Daily weights d. Skin turgor

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. Hypotension b. Tachycardia c. Anxiety

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. inflammatory

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. tetracycline

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? a.1 b.2 c.3 d.4

a.1

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.A urine output consistently above 40 ml/hour b.A weight gain of 4 lb (2 kg) in 24 hours c.Body temperature readings all within normal limits d.An electrocardiogram (ECG) showing no arrhythmias

a.A urine output consistently above 40 ml/hour

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

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

a.Capillary leak

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

a.Deep partial thickness

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 burns usually follow an internal path.

Which type of burn injury requires skin grafting? a.Full-thickness b.Superficial c.Superficial partial-thickness d.Deep partial-thickness

a.Full-thickness

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. "A snug fit is needed to minimize scarring and overgrowth of skin."

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. "Are the burns associated with chemicals used in the plant?"

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

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.Hyperkalemia.

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

a.It compromises wound healing and immunocompetence.

Which of the following is the analgesic of choice for burn pain? a.Morphine sulfate b.Fentanyl c.Demerol d.Tylenol with codeine

a.Morphine sulfate

After being exposed to smoke and flames from a house fire, which assessment finding is most important in determining care of the client? a.Presence of soot around nasal passages b.Fracture of the fibula with displacement c.Elevation of blood pressure and heart rate d.Partial-thickness burns to hands and wrists

a.Presence of soot around nasal passages

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.Pulmonary system

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.Roll the client in a blanket.

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? a.Superficial b.Full-thickness c.Superficial partial-thickness d.Deep partial-thickness

a.Superficial

Which type of burn is similar to a sunburn? a.Superficial partial-thickness b.Electrical c.Deep partial-thickness d.Full-thickness

a.Superficial partial-thickness

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

a.face, neck, chest

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? a.full thickness (third degree) b.superficial (first degree) c.superficial partial-thickness or deep partial-thickness (second degree) d.fourth degree

a.full thickness (third degree)

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

a.hemoconcentration

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.inflammatory

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

A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body? a.9% b.18% c.27% d.36%

c.27%

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

c.5 days

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.Immerse the child's legs in cool water.

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 conditions

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? a. Face only b. Face, neck, and chest c. Face and neck d. Neck and chest

d. Neck and chest

An emergency department nurse is evaluating a client with partial-thickness burns to the entire surfaces of both legs. Based on the rule of nines, what is the percentage of the body burned? a.9% b.18% c.27% d.36%

d.36%

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.K+: 5.0 mEq/L b.Na+: 145 mEq/L c.Ca: 9 mg/dL d.BUN: 28 mg/dL

d.BUN: 28 mg/dL

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 of the voice

Following a serious thermal burn, which complication will the nurse take action to prevent first? a.Tissue hypoxia b.Infection c.Renal failure d.Hypovolemia

d.Hypovolemia

A nurse formulates a nursing diagnosis of Impaired physical mobility for a client with full-thickness burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase? a.Related to fat emboli b.Related to infection c.Related to femoral artery occlusion d.Related to circumferential eschar

d.Related to circumferential eschar

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 early appearance of the burn injury may change.

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.decrease catabolism.

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.pain management.