PU CH57 BURNS PART II

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. Infection Risk D. Altered Tissue Perfusion

A

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

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

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. Pain management B. Fluid resuscitation C. Infection D. Body image

A

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 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

Formulas are only a guide for burn care fluid resuscitation. How often must the patient' s response to fluid therapy (heart rate, blood pressure, and urine output) be evaluated? A. Every hour B. Every 2 hours C. Every 3 hours D. Every 4 hours

A

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

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

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

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

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

Which type of burn injury requires skin grafting? A. Full-thickness B. Superficial C. Superficial partial-thickness D. Deep partial-thickness

A

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. A. "This medication is an antibacterial." B. "This medication will be applied directly to the wound." C. "This medication will stain my skin permanently." D. "This medication will help my burn heal."

A B D

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

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 A. Qrevent infection B. Fluid resuscitation C. Endotracheal tube placement D. Strict intake and output

B

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

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

Following a burn injury, the nurse determines which area is the priority for nursing assessment? A. Cardiovascular system B. Pulmonary system C. Pain D. Nutrition

B

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

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? A. Hypernatremia B. Hypokalemia C. Hyperkalemia D. Hypercalcemia

B

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

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

Which type of debridement occurs when nonliving tissue sloughs away from uninjured tissues? A. Mechanical B. Natural C. Enzymatic D. Surgical

B

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

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? A. Removal of clothing B. Irrigation of the wound C. Application of ice D. Removal of hair

C

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

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? A. Elevate the leg on pillows and reassess the leg in 1 hour. B. Document the findings and instruct the client to report numbness of the extremity. C. Contact the primary care provider and prepare for an escharotomy. D. Apply an elastic stocking to the extremity and administer SQ heparin per order.

C

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

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

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