prepU burns

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

The palm represents which percentage of a person's TBSA?

1%

A patient is being discharged after sustaining a deep-partial thickness burn during a house fire. The patient is asking when the burn will be healed. The nurse understands that this type of burn injury heals within which of the following time frames?

2 to 4 weeks

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?

2,400 mL

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?

36%

The nurse is planning the care of a patient with a major thermal burn. What outcome will the nurse understand will be optimal during fluid replacement?

A urinary output of 30 mL/hr

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

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?

Application of ice

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?

Apply a cervical collar on the client

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:

Epidermis and a portion of deeper dermis.

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

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

Biobrane

Which complication is common for victims of electrical burns?

Cardiac dysrhythmia

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately?

Hoarseness of the voice

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

Fluid resuscitation

Which zone of burn injury sustains the most damage?

Inner

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?

Instruct to pat and not scratch the areas.

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?

Homografts

A child tips a pot of boiling water onto his bare legs. The mother should:

Immerse the child's legs in cool water.

Which is the primary reason for placing a client in a horizontal position while smothering flames are present?

To keep fire and smoke from airway

Which of the following is the analgesic of choice for burn pain?

Morphine sulfate

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?

Paralytic ileus

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.

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

The nurse is caring for a client with burns over 55% of total body surface area. Which information is essential for the nurse to document to guide the care of this client? Select all that apply.

Pre-burn body weight Current list of medications Last tetanus immunization Current body temperature

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?

Preexisting conditions

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

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 circumferential eschar

A nurse is aware that after a burn injury and respiratory difficulties have been managed, the next most urgent need is to:

Replace lost fluids and electrolytes.

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.

Which type of burn injury requires skin grafting?

full thickness

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. How would the nurse document the depth of burn injury this client has?

full thickness (third degree)

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

inflammatory

Determining the depth of a burn is difficult initially because there are combinations of injury zones in the same location. The area of intermediate burn injury is the zone in which blood vessels are damaged, but tissue has the potential to survive. This is called the zone of:

stasis

Which antimicrobials is not commonly used to treat burns?

tetracycline

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 burns associated with chemicals used in the plant?"

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."

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

27%

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?

27%

Acticoat antimicrobial barrier dressings used in the treatment of burn wounds can be left in place for which time frame?

5 days

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?

Contact the primary care provider and prepare for an escharotomy.

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?

Deep partial-thickness

A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client?

Gastric ulcers

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.

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?

Hyperkalemia

Which of the following is to be expected soon after a major burn? Select all that apply.

Hypotension Tachycardia Anxiety

The nurse receives a client following a serious thermal burn. Which complication will the nurse take action to prevent first?

Hypovolemia

Which of the following site is the source of most microbes leading to bacterial infection?

Intestinal tract

Which type of debridement occurs when nonliving tissue sloughs away from uninjured tissues?

Natural

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?

Neck and chest

Following a burn injury, the nurse determines which area is the priority for nursing assessment?

Pulmonary system

Which of the following fluid or electrolyte changes occur in the emergent/resuscitative phase?

Reduction in blood volume

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 has experienced extensive full-thickness burns.

As the first priority of care, a patient with a burn injury will initially need:

a patent airway established.

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

decreased catabolism.