N4 Midterm Management of Patients with Burn Injury Prep U

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%.

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.

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.

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.

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.

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 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 will help my burn heal." "This medication is an antibacterial." "This medication will be applied directly to the wound."

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.

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:

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.

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.

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.

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.

A client is brought to the emergency department by a coworker following a burn injury from a high-voltage electrical power line. The triage nurse determines which intervention should be completed first? Take the client's vital signs Apply a cervical collar on the client Insert a urinary Foley catheter Obtain a 12-lead ECG

Apply a cervical collar on the client Explanation: Until it is known that the client has no fractures, it is imperative that a neck collar be applied and remain in place and that the client is log rolled to eliminate the chance of further spinal cord injury. With high-voltage electrical injuries, cervical spine immobilization is a priority until cervical spine injury is ruled out. The other interventions may be completed; however, the priority intervention is to apply the collar.

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.

Which type of graft utilizes the client's own skin for wound coverage? Heterograft Allograft Autograft Slit graft

Autograft Explanation: An autograft uses the client's own skin, which is transplanted from one part of the body to another. A heterograft is obtained from animals, principally pigs. An allograft is human skin obtained from a cadaver. A slit graft is used when the area available as a donor site is limited, as in clients with extensive burns.

Which zone consists of the area where the injury is most severe and deepest? Coagulation Stasis Hyperemia Necrosis

Coagulation Explanation: The zone of coagulation is at the center of the injury and is the area of injury that is most severe and the deepest. The zone of stasis is the area of intermediate burn injury. The zone of hyperemia is the area of least injury, where the epidermis and dermis are only minimally damaged. There is no zone of necrosis.

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.

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? Electrical burns usually follow an internal path. Lightning is higher in voltage than electricity. The skin is a good conductor of electricity. Moisture intensifies the damage inflicted.

Electrical burns usually follow an internal path. Explanation: Electrical current follows the path of less resistance. Because the 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 is brought to the ED with burns exceeding 20% of total body surface area. Which is the primary nursing intervention in the care of this client Prevent infection Fluid resuscitation Endotracheal tube placement Strict intake and output

Fluid resuscitation Explanation: 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.

Which type of burn injury requires skin grafting? Full-thickness Superficial Superficial partial-thickness Deep partial-thickness

Full-thickness Explanation: A full-thickness burn injury heals by contraction or epithelial migration and requires grafting. The other types of burn injury do not require skin grafting.

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.

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.

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.

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

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.

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.

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.

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? Rule of nines Lund and Browder method Hand method Parkland formula method

Lund and Browder method Explanation: 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.

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

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.

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.

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.

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? Age Weight Preexisting conditions Family history

Preexisting conditions Explanation: 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.

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.

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.

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

Related to circumferential eschar Explanation: As edema develops on circumferential burns, eschar forms a tight, constricting band, compromising circulation to the extremity distal to the circumferential site and impairing physical mobility. This client isn't likely to develop fat emboli unless long bone or pelvic fractures are present. Infection doesn't alter physical mobility. A client with burns on the lower portions of both legs isn't likely to have femoral artery occlusion.

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.

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.

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.)

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.

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

Tachycardia, slight hypotension, and anxiety are expected soon after the burn.

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 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.

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.

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.

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.

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

Application of ice Explanation: Application of ice causes vasoconstriction and diminishes needed blood flow to the zone of injury. Clothing and hair are removed from perimeter of burned area in an effort to remove course of bacterial contamination. Irrigation of the wound assists in the removal of debris.

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.

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 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.

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.

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.

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.

The nurse participates in a health fair about fire safety. When clothes catch fire, which intervention helps to minimize the risk of further injury to an affected person at a scene of a fire? Roll the client in a blanket. 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: 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.

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.

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.

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.

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.

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.

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.

Which complication is common for victims of electrical burns? Inhalation injury Infection Cardiac dysrhythmia Hypovolemic shock

Cardiac dysrhythmia Explanation: Cardiac dysrhythmias are common for victims of electrical burns. If the patient has an electrical burn, a baseline electrocardiogram (ECG) is obtained and continuous monitoring is initiated. Any burn injury can lead to complications, such as inhalation injury, infection, and hypovolemic shock.

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.

A client has been burned significantly in a workplace accident. Which conditions create the need for immediate intensive care by specifically trained personnel? Select all that apply. Wound care Nutritional support Fluid loss Fluid shift Hypotension

Fluid loss Fluid shift Hypotension Fluid shift, fluid loss, and hypotension can lead to irreversible shock. These changes usually happen rapidly and the client's status may change from hour to hour, requiring that clients with burns receive intensive care by skilled personnel. Wound care and nutritional support are important, but not immediate, client needs.

The nurse is preparing to provide wound care to a client with extensive burns. Which characteristic of the dressing will the nurse use to select the type of topical therapy? Select all that apply. Penetrates eschar without toxicity Used for the duration of the wound care Effectiveness against organisms Cost-effective and acceptable to the client Easy to apply and remove to minimize pain

Penetrates eschar without toxicity Effectiveness against organisms Cost-effective and acceptable to the client Easy to apply and remove to minimize pain Variations in topical wound care for nonsurgical burn wounds exist among burn centers across the country. Selections are based on the individualized needs of each client. The goal of topical therapy is to provide a dressing with specific characteristics to include the ability to penetrate eschar without causing systemic toxicity and treat the invading organism. The topical application and dressing must be cost-effective, available, and acceptable to the client. The topical application and dressing must also be easy to apply and remove to minimize pain. No single topical medication is universally effective, and the use of different agents at different times in the post-burn period is the best practice.

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.

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.

Name three major antimicrobials used to treat burns.

Silver sulfadiazine (Silvadene), mafenide (Sulfamylon), and silver nitrate (AgNO3) 0.5% solution are the three

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.