Burn

[MoC] The nurse is planning the care for clients recovering from second- or third-degree burns. Which psychosocial nursing problem should be priority? 1. Altered sensory perception 2. Altered skin integrity 3. Disturbed body image 4. Disturbed personal identity

1. Altered sensory perception is a physiological problem. 2. Altered skin integrity is a physiological problem. Correct Answer: 3 3. Disturbed body image occurs during the recovering stages of the burn condition and should be priority. 4. Disturbed personal identity is less likely to occur than disturbed body image. Test-taking Tip: Focus on psychosocial nursing problems and eliminate any option that is physiological nursing problem. Of the remaining options, determine which is most likely to occur. (page 516)

The nurse from the oncology unit was reassigned to a burn unit due to a staffing need. Which client should the charge nurse plan to assign to the nurse from the oncology unit? 1. 23-year-old newly admitted with burns on 30% of the body from a house fire 2. 27-year-old recent skin graft recipient needing nutrition and wound care teaching 3. 29-year-old with partial-thickness back and chest burns needing a sterile dressing change 4. 30-year-old with full-thickness burns on both arms needing help with positioning

1. An experienced nurse in the burn unit should care for the newly admitted client due to complex needs of the client. 2. An experienced nurse in the burn unit should complete the nutrition and wound teaching because the client is likely to have questions that may be unfamiliar to an oncology nurse. Correct Answer: 3 3. The 29-year-old client is the most stable. The nurse from the oncology unit should be able to complete a sterile dressing change. 4. An experienced nurse in the burn unit should care for the client who requires assistance with positioning in hand splints; the nurse from the oncology unit may be unfamiliar with the splints. Test-taking Tip: Eliminate clients who have complex care issues. The nurse inexperienced in caring for clients on a burn unit should have the most stable client. (page 86)

[PHARM] The nurse is caring for clients with second-and third-degree burns. Which medication should the nurse plain to apply topically to treat bacterial and yeast infections? 1. Bismuth subsalicylate 2. Gold sodium thiomalate 3. Silver sulfadiazine 4. Arsenic trioxide

1. Bismuth subsalicylate (Kaopectate) is an antidiarrheal medication. 2. Gold sodium thiomalate (Aurolate) is used to treat rheumatoid arthritis resistant to conventional therapy. Correct Answer: 3 3. Silver sulfadiazine (Silvadene) is a topical anti-infective agent for prevention and treatment of wound infection in second- and third-degree burn clients. 4. Arsenic trioxide (Trisenox) is an antineoplastic. Test-taking Tip: Note the key word "Typically" in the stem. Only one option is a topical medication. (page 517)

After touching a hot oven grate, the client telephones the ED asking for advice for the singed fingers. Which initial statement by the nurse is most appropriate? 1. "Wrap ice in a washcloth and put it on the burn area." 2. "Come to the ED so a doctor can assess your fingers." 3. "Run cool water over the burned area on your fingers." 4. "Apply an antibiotic skin ointment to prevent infection."

1. Ice causes vasoconstriction and can worsen the tissue damage. 2. The nurse should collect additional information before advising that the client be seen in the ED. A first-degree burn ordinarily does not require medical care. Correct Answer: 3 3. Cool water will minimize skin redness, pain, and swelling and limit tissue damage. 4. Applying a skin ointment as an initial intervention can trap heat in the tissues; if it has an oily base, it can prevent healing. Test-taking Tip: The key word is "signed," indicating that the burn is superficial. Consider actions for a first-degree burn. (page 516)

The parent brings the 2-year-old child into an urgent care setting with blistering burns due to sun exposure. Following an initial assessment, which action should be the nurse's priority? 1. Determine percent of burn injury 2. Administer an analgesic medication 3. Open the blisters for débridement 4. Apply cool compresses for 20 minutes

1. Percent of burn injury would be determined with the overall assessment. 2. Pain medications should be administered as soon as the toddler's pain level is determined and would be the next priority. 3. Blisters should be left intact, not opened. After the blister has burst, only devitalized tissues would be débrided. Correct Answer: 4 4. The first priority is to stop the burning process and relieve the pain. Cool compresses will accomplish both. Epidural burns, such as sunburns, are painful. Test-taking Tip: The main priority is to stop the burning process and relieve the pain. You should consider what action would be the fastest. (page 90)

The nurse assess that the client with partial-thickness burns over 50% of the total body surface area (TBSA) has gained weight and has generalized edema after the first 24 hours. The nurse should consider that the edema and weight gain are most likely related to which physiological processes? 1. Elevated serum sodium and potassium levels 2. Increased hemoglobin and hematocrit levels 3. Excess intravenous fluid volume replacement 4. Leakage of plasma into the interstitial space

1. Sodium is ost due to diuresis, and existing sodium tends to be diluted by an influx of fluid, so serum sodium levels will be decreased, not increased. Potassium may initially increase due to massive cellular destruction and release of intracellular potassium. 2.Hgb and Hct levels may change in severe burns, but they are the result of the fluid shift, not the cause. 3. Fluid volume deficit (not excess) is a major risk during this phase; therefore, large amounts of IV fluids are administered. However, this does not explain the underlying physiological process that cause the edema. Correct Answer: 4 4. Initially after a severe burn injury there is a loss of capillary integrity and a shift of fluid, sodium, and protein from the intravascular to the interstitial spaces. The body compensates for this interstitial hemoconcentration by retaining more fluid. Test-taking Tip: Visualize the damage to the cellular structures as a result of a burn and how this would affect fluid balance. (page 517)

The nurse determines that the fluid status of the client with a second-degree burn is inadequate and immediately notifies the HCP. The client is 5 hours postburn and weighs 60 kg. Which findings prompted the nurse's action? 1. Blood pressure 92/60 mm Hg and pulse 100 bpm 2. Respirations 19 per minute and pulse 60 bpm 3. Pulse 130 bpm and urine output 25 mL/hr 4. Pulse 106 bpm and temperature 98.4°F (36.9°C)

1. The MAP for a BP of 92/60 mm Hg is 70.7, indicating adequate perfusion (MAP = [systolic BP + diastolic BP = diastolic BP] ÷ 3 = 70.7). A pulse of 100 bpm is WNL. 2. Respirations of 18 per minute and pulse of 60 bpm are both WNL. Correct Answer: 3 3. The client weighing 60 kg weighs 132 lb (1 kg = 2.2 lb). For the adult client weighing 132 lb, a pulse rate of 130 bpm (tachycardia) and a low urine output of 25 mL/hr are signs of inadequate circulating fluid volume. 4. A pulse of 106 bpm could be elevated due to pain, and the temperature of 98.4°F (35.9°C) is considered normal. These alone would not indicate inadequate fluids. Test-taking Tip: Tachycardia and a urine output of less than 30 mL/hr could indicate inadequate fluid in volume. (page 516)

The nurse is caring for the client with a large, open sternal wound resulting from a burn injury. The client is receiving eternal feeding, Oxepa (an anti-inflammatory, pulmonary 1.5 Cal/mL formula), at 25 mL/hour. Which laboratory value finding best indicates that the client is receiving inadequate nutrition? (please refer to Davis's Q&A Revie for NCLEX-RN second edition, page 517, question 1366 table) 1. Phosphorus 2. Platelets 3. Prealbumin 4. Potassium

1. The phosphorus level decreases in malnutrition as well as other conditions, but this is not the best indicator of inadequate nutrition. 2. The platelets are essential to blood clotting and may or may not be altered with inadequate nutrition. Correct Answer: 3 3. Prealbumin is used to evaluate nutritional status. A low level of prealbumin indicates inadequate nutrition. Prealbumin has a half-life of 2 days and reflects changes in serum protein stores more rapidly than other indices. 4. Potassium is the major cation within the cell and may be low due to renal failure or GI disorders. It may or may not be altered with inadequate nutrition. Test-taking Tip: Note the key words "inadequate nutrition" and focus on what this means. Eliminate options that do not measure protein stores. (page 517)

When assessing a burn victim's skin the nurse notices the entire right and left upper extremities are red, moist, weeping, and blistered. How should the nurse document the degree and total body surface area (TBSA) burned? 1. First-degree burn on 9% TBSA 2. Partial-thickness burn on 18% TBSA 3. Partial-thickness burn on 27% TBSA 4. Full-thickness burn on 36% TBSA

1. This is not a first-degree burn. In a first-degree burn the skin may appear red but intact, no weeping, and no blistering. In an adult, one upper extremity is approximately 9% of the TBSA. However, in this example both upper extremities are burned, which equals 18% TBSA. Correct Answer: 2 2. Partial-thickness burns damage the dermis and epidermis, often resulting in loss epidermis and/or blistering. Each entire upper extremity is blistered. Approximately 18% of the TBSA has partial-thickness burn (9% TBSA per each upper extremity). 3. With full-thickness burns there would be loss of tissue and a black or white charred/waxy appearance to the remaining tissues. In addition, the % TBSA is too high for a burn affecting only the upper extremities. 4. With full-thickness burns there would also be loss of tissue and a black or white charred/waxy appearance. In addition, the % TBSA is too high for a burn affecting only the upper extremities. Test-taking Tip: To calculate % TBSA, use the palmar rule, where the client's palm size equals 1%; or apply the Rule of Nines for calculating, where each upper extremity equals 9%; or visualize the body and estimate the % TBSA for both upper extremities. Pick the option that is closest to your estimate. (page 516)

The client sustained partial- and full-thickness burns to the anterior left and right arms, anterior chest and abdominal area, and anterior left leg. Using the Rule of Nines, what is the estimated extent of this injury that the nurse should document? _____% (Record your answer as a whole number.)

According to the Rule of Nines, this client sustained injuries on about 36% of the body surface: right arm is 4.5%; left arm is 4.5%: left leg is 9%; anterior chest and abdomen are 18%. Test-taking Tip: Use the Rule Nines. The body is divided into areas of multiples of 9% with the perineal area being 1%. The palm of the client's hand is approximately equal to 1%. (Page 517)

[PHARM] The nurse completes teaching the client with a second-degree burn about silver sulfadiazine. Which client statements should indicate to the nurse that the teaching was effective? Select all that apply. 1. "I apply the cream only to the opened areas of the burned area." 2. "Silver sulfadiazine will prevent infection of the burned area." 3. "I never should apply a dressing after applying silver sulfadiazine." 4. "I use a tongue blade to remove the old ointment before reapplying." 5. "The cream is dark colored and cannot be removed with water."

Answer: 1, 2 1. Silver sulfadiazine (Silvadene) is only applied to opened areas; this statement indicates client understanding of the instructions. Answer: 1, 2 2. Silver sulfadiazine is used to reduce/prevent bacterial growth and thus and infection; this statement indicates client understanding of the instructions. 3. Dressings can be applied but are not necessary; this statement does not indicate client understanding. 4. Removal of old ointment with a tongue blade can damage new granulation tissue; this statement does not indicate client understanding. 5. The cream is white in color and water-soluble; if it darkens it should not be used; this statement does not indicate client understanding. Test-taking Tip: Options with absolute words such as "never" are usually incorrect. (page 516)

[PHARM] The nurse is determining the IV fluid needs for the 50-kg client with partial-thickness burns to 40% total body surface area (TBSA). Using the Parkland formula (4 mL x weight in kg x % TBSA burn = 24-hour IV fluid volume replacement; half given in first 8 hours), how many mL of IV fluid are needed during the first 8 hours after injury? _____ mL of IV fluid (record your answer as a whole number.)

Answer: 4000 Use the Parkland formula provided: 4.0 mL x 50 kg = 200 mL; 200mL x 40% TBSA burn = 8000 mL. Half of 8000 mL, or 4000 mL, is given in the first 8 hours after the burn. Test-taking Tip: Read the formula carefully; then plug the values into the formula. If you change 40% to a decimal, you will get the wrong amount. (page 517)

Three days ago the client received circumferential, partial, and full-thickness burns to 30% total body surface area of the chest and abdomen. The nurse monitors the client for restricted breathing due to which physiological response? 1. Development of a layer of eschar 2. Loss of elastin and collagen in the tissues 3. Hypoxia and ischemia of the lungs' alveoli 4. Fluid overload in the alveoli of the lungs

Correct Answer: 1 1. A layer of eschar or devitalized tissue commonly forms over partial- and full-thickness burns, which, when circumferential and when combined with increased fluid retention, can restrict circulation and lung expansion. 2. Loss of tissue containing elastin and collagen does occur in partial- and full-thickness burns but would not be a source of constriction that would prevent lung expansion. 3. Ischemia and hypoxia may be experienced in the alveoli due to inhalation burns; however, restricted breathing (a mechanical process) is more of a risk due to circumferential eschar formation. 4. Although fluid overload is a possibility, it is not likely to restrict breathing unless it is combined with eschar formation. Test-taking Tip: Key information in the stem is the character of the burn, its depth, extent, and the fact that it is circumferential. Eschar is devitalized tissue. Consider how this could restrict breathing. (page 516)

The nurse is providing postoperative care for the client with a split-thickness skin graft on the burn wound at the sole of the right foot. Which is appropriate care for this client? 1. Immobilization of the graft site 2. Weight-bearing exercises to the graft site 3. Assist client out of bed as much as tolerated 4. Maintain right leg in a dependent position

Correct Answer: 1 1. The graft must be immobilized so that it can remain in place and be able to revascularize. 2. The client cannot place weight on the graft site. Bearing weight causes trauma. 3. The graft site has to stay immobile. There can be no weight on the graft site. 4. A dependent position impairs circulation and may cause further tissue injury. Test-taking Tip: Anything that may loosen the graft should be avoided. (page 517)

The nurse is caring for the client with problems of anxiety and confusion in the critical phase of burn injury. Which interventions should the nurse implement? Select all that apply. 1. Repeat orientation statements of person, place, and time. 2. Turn and reposition the client at least every 2 hours. 3. Place familiar objects from home near the client. 4. Implement a schedule for regular sleep-wake cycles. 5. Control distractions by keeping the room door closed. 6. Encourage the client to write notes to family members.

Correct Answer: 1, 3, 4 1. Reiterating statements of orientation to the client decreases confusion. 2. Turning and repositioning improves circulation and aeration but does not affect confusion. Turning can increase the client's anxiety. Correct Answer: 1, 3, 4 3. Familiar objects reduce anxiety when clients are in unfamiliar surroundings. Correct Answer: 1, 3, 4 4. Employing a regular schedule for sleep-wake cycles assists in decreasing confusion and anxiety. 5. Closing the door of the room may increase client anxiety. 6. In the acute phase of burns, the client is too ill to write notes to family members. Test-taking Tip: Note the key phrase "anxiety and confusion" and focus on interventions that can decrease these symptoms. You should be alert that the client is critical. (Page 517)

The client who has bilateral hand burns reports wearing soft contact lenses that need to be removed. Which action(s) are important for the nurse to include in this procedure? Select all that apply. 1. Perform hand hygiene and don gloves. 2. Pinch the lens over the pupil and remove. 3. Place the lens in a sterile container with normal saline. 4. Irrigate the eye with normal saline to loosen the lens. 5. Instruct the client to look up when removing the lens.

Correct Answer: 1, 3, 5 1. Hand hygiene reduces introduction of microorganisms into the eye. Donning gloves prevents exposure to blood or body fluids. 2. The lens should slide down off the pupil before pinching and removing to prevent corneal abrasion. Correct Answer: 1, 3, 5 3. The lens needs to be kept moist. If contact lens solution is unavailable, sterile normal saline is the best option. 4. Irrigating the eye could result in loss of the lens or injury to the cornea. Correct Answer: 1, 3, 5 5. Instructing the client to look up allows the nurse to slide the lens down off the pupil before removing it. Test-taking Tip: Focus on eliminating actions that could result in injury to the cornea. (page 239)