Burns

A child was admitted to the ED with a thermal burn to the right arm and leg. Which assessment by the nurse requires immediate action? a. coughing and wheezing b. bright red skin with small blisters c. thirst d. singed hair

a. coughing and wheezing may indicate the child has inhaled smoke or toxic fumes. AIRWAY

The rate at which IV fluids are infused is based on the burn client's a. lean muscle mass and body surface area burned b. total body weight and BSA burned c. total BSA and BSA burned d. height and weight and BSA burned

b. During the first 24 hours, fluid replacement is calculated on total body weight and BSA burned.

BUN

6-20

Type of burn caused by tar, the dermis and subcutaneous fat layer are damaged

Full thickness burn

Creatinine

0.6-1.3

Type of burn caused by grease. The deep layers of the skin are damaged.

Deep Partial - thickness burn

Type of burn caused by a flame or a water scald. The entire epidermis layer of skin is damaged.

Superficial partial-thickness burn

A nurse working in a provider's office is assessing a client who has a severe sunburn. Which of the following is the proper classification of this burn? a. superficial b. superficial partial-thickness c. deep partial-thickness d. full-thickness

a. A sunburn is superficial. Superficial burns damage the top layer of the skin

When counseling clients regarding first-line burn prevention, the nurse should plan to include which of the following items? a. temperature setting on the hot water tank b. demonstration of the use of a fire extinguisher c. assistance in the planning of an escape route d. stress the need for smoke detectors.

a. most burns occur at home and caused by hot water or steam

The nurse should plan to begin rehabilitation efforts for the burn client a. immediately after the burn has occurred b. after the client's circulatory status has been stabilized c. after grafting of the burn wounds has occurred d. after the client's pain has been eliminated

b. after the client's circulatory status has been stabilized Early emphasis on rehab is important to decrease complications.

A client with burn injury asks the nurse what the term "full thickness" means. The nurse should respond that burns classified as full thickness involve tissue distraction down to which level? a. epidermis b. subcutaneous tissue c. internal organs d. dermis

b. subcutaneous tissue (this is below the dermis) May also include the fat

Albumin (biggest indicator of nutritional status)

3.4-5.4

A health care provider admitted a client with second and third degree burns over 60% of the body. Fourteen hours later, the client is receiving lactated Ringer's at 200 mL/hr. Which intervention is the priority at this time? Begin hourly range of motion. Monitor hourly urine output. Administer morphine sulfate prn. Assess burned areas for signs and symptoms of infection.

Monitor hourly urine output Fluid resuscitation is a priority in the first 24 hours after a burn to prevent the onset of shock and system collapse. Urine output is the most readily available and reliable indicator for determining the adequacy of fluid replacement. Assessing for infection is important as are pain control and range of motion; however, during the shock phase, adequacy of fluid resuscitation should be the priority. Pain is a high priority after fluid resuscitation has begun.

During the shock phase of the burn injury in a severely burned client, which assessment findings indicate that the client is receiving adequate fluid volume replacement? Restless, confused as to time and place, urine output 20 mL/ hr, and weight gain of 5 lb Bounding pulse, rales on expiration, weight gain >5 lb/24 hrs Urine output 45 mL/hr, BP 100/60, and oriented to person and place Weak pulses, BP 85/50, pulse 120, and hematocrit 50%

Urine output 45 mL/hr, BP 100/60, and oriented to person and place Fluid replacement is considered adequate when urine output is 30-50 mL/hr or 0.5 mL/kg/hr, blood pressure is stable, pulses are palpable, central venous pressure (CVP) is 7-10, and potassium level is 3.5-5.3. A clear sensorium is another positive sign of adequate fluid replacement. Weight gain is not an issue with fluid resuscitation.

A nurse is caring for a client who was admitted 24 hours ago with deep partial thickness and full thickness burns to 40% of his body. Which of the following are expected findings in this client? (select all) a. hypertension b. bradycardia c. hyperkalemia d. hyponatremia e. decreased hematocrit

c. hyperkalemia occurs when a client is in shock as a result of leakage of fluid from the intracellular space. d. hyponatremia occurs as a result in sodium retention in the interstitial space. a. hypotension b. tachycardia e. increased hematocrit

An advantage of using biologic burn grafts such as porcine (pigskin) grafts is that they appear to help a. encourage formation of tough skin b. promote growth of epithelial tissue c. provide for permanent wound closure d. facilitate development of subcutaneous tissue

b. biologic dressings serve many purposes Enhance growth of epithelial tissues Minimize overgrowth of granulation tissue Prevent loss of water and protein Decrease pain and increase mobility Help prevent infection

The nurse is caring for a client with full thickness burns on 50% of his body. The spouse asks "Why does he look so different? He's all puffy." What is the best response by the nurse? a. We are giving him a great deal of IV solutions and that is causing the edema b. it is normal at this stage of a burn injury c. the burn causes his fluids to shift into his tissues and that is causing the puffiness d. when he received his diuretic, most of the puffiness will go away

c. After a burn, the blood vessels dilate and fluid leaks into the interstitial spaces. This is known as third spacing .

The nurse is caring for a client admitted to the ED following a fire. The client has a BP of 96/62 and has partial thickness burns on the chest and neck. The nurse's immediate response is to: a. hang a saline infusion wide open to keep the BP WNL b. cleanse the skin with sterile saline to prevent infection c. call the physician and prepare to intubate the client d. observe the client for evidence of distress

c. Clients with burns around the face are at risk for an inhalation injury. The edema that results can be sudden and occlude the airway almost immediately.

The nurse is conducting a focused assessment of the GI system of a client with a burn injury. The nurse should assess the client for a. paralytic ileus b. gastric distention c. hiatal hernia d. Curling's ulcer

d. Curling's ulcer occurs in about half of the clients with a burn injury.

A priority nursing diagnosis for a client with burns during the emergent period would be? a. excess fluid volume b. imbalanced nutrition: less than body requirements c. risk for injury d. risk for infection

d. Infection is a priority problem in a burn victim

When caring for a client after an escharotomy, how should the nurse explain to the client the reason for the procedure? The procedure permits blood to flow more easily. A skin graft will prevent scarring of the area. The procedure does not remove any tissue. The procedure will prevent infections.

Permits blood to flow more easily. An escharotomy is performed to prevent arterial occlusion and resulting gangrene in a circumferential burn. Skin grafting will probably be necessary and scarring will result. Dead tissue may be excised and scrupulous wound care is necessary to prevent infection.

Using the Parkland Formula, calculate the hourly rate of fluid replacement with LR during the first 8 hours for a client weighing 75 kg with total BSA burn of 40%. _____mL/hr

750 mL/hour Formula: 4 mL x kg x TBSA Give half over the first 8 hours and the second half over the next 16 hours.

The child has just been admitted to the pediatric burn unit. Currently, the child is being evaluated for burns to his chest and upper legs. He complains of thirst and asks for a drink. What is the most appropriate nursing action? a. give small glass of clear liquid b. give a small glass of a full liquid c. keep the child NPO d. order a pediatric meal tray with extra liquids

c. NPO A complication of major burns is a paralytic ileum, so until that has been ruled out, oral fluids should not be provided.

A nurse is caring for a client who has sustained burns to 35% of his total body surface area. Of this total, 20% are full-thickness burns on the arms, face, neck, and shoulders. The client's voice is hoarse, and he has a brassy cough. These findings are indicative of which of the following? a. pulmonary edema b. bacterial pneumonia c. inhalation injury d. carbon monoxide poisoning.

c. Wheezing and hoarseness are indicative of inhalation injury.

Which of the following activities should the nurse include in the plan of care for a client with burn injuries to be carried out about one-half hour before the daily whirlpool bath and dressing change? a. soak the dressing b. remove the dressing c. administer an analgesic d. slit the dressing with blunt scissors

c. administer an analgesic.

A client with severe burns is receiving ranitidine hydrochloride (Zantac) 50 mg IV every 6 hours. What is the rationale for this therapy? Management of moderate pain Vitamin supplementation Prevention of Curling's ulcers Ongoing treatment for a client history of gastritis

Prevention of Curlin's ulcers Clients with burns or any significant degree of stress are very susceptible to the development of Curling's ulcers (stress ulcers). Ranitidine is an H2 receptor antagonist and will decrease acid secretion, thereby preventing formation of stress ulcers. It is not used for treatment of gastritis or pain, nor is it a vitamin supplement.

When caring for a client with a burn in the emergent stage, which of the following has lowest priority as part of an accurate burn assessment? a. where it occurred b. cause of the burn c. first aid treatment given d. gender

d. gender is not a factor

During the early phase of burn care the nurse should assess the client for? a. hypernatremia b. hyponatremia c. metabilic alkalosis d. hyperkalemia

d. hyperkalemia Immediately after a burn, excessive K+ from cell destruction is released into the extracellular fluid.

The client with a major burn injury receives TPN. The expected outcome is to a. correct water and electrolyte imbalances b. allow the GI tract to rest c. provide supplemental vitamins and minerals d. ensure adequate caloric and protein intake

d. nutritional support with sufficient calories and protein is extremely important because of the loss of plasma protein through injured capillaries and an increased metabolic rate.

Which of the following factors would have the least influence on the survival and effectiveness of a burn victim's porcine grafts? a. absence of infection in the wounds b. adequate vascularization in the grafted area c. immobilization of the area being grafted d. use of analgesics as necessary for pain relief

d. use of analgesics

A client is receiving fluid replacement with LR after 40% of his body was burned 10 hours ago. The assessment reveals: Temp 36.2, HR 122, BP 84/42, CVP 2 mm, and urine output 25 mL for the last two hours. The IV rate is currently at 375 mL/hr. Using the SBAR technique for communication, the nurse calls the healthcare provider with the recommendation for a. furosemide b. fresh frozen plasma c. IV rate increase d. dextrose 5%

c. The decreased urine output, low blood pressure, low CVP, and high heart rate indicate hypovolemia and the need to increase fluid volume replacement.

After the initial phase of the burn injury, the client's plan of care will focus primarily on a. helping the client maintain a positive self image b. promoting hygiene c. preventing infection d. education the client regarding care of the skin

c. preventing infection In burn injury, the immune system is impaired.

An adult client was severely burned in a grass fire resulting in second degree burns on the left arm, leg, and back as well as third degree burns on the right arm. Using the rule of nines, the estimated extent of burns is: 54%. 27%. 45%. 36%.

54% The rule of nines is a quick assessment scale used to estimate the extent of burn injury. The body is divided into areas that represent 9% of the body surface area. This client had burns of the following percentages: R arm 9%, L arm 9%, L leg 18%, back 18% for a total of 54%.

GFR

90-120

An adolescent who experienced major burns two months ago is ready for discharge. Which statement best reflects that the child and family understand the discharge care? "I will apply cold packs to my arms three times a day for at least half an hour." "I really need to stick to the high-carbohydrate, high-calorie diet that I had in the hospital." "I will be so glad to be home and not need to wear this pressure covering on my arms anymore." "I will call my doctor if I have a fever or my arms have any drainage."

I will call my doctor if I have a fever or my arms have drainage. The discharged client and family must be alert to signs and symptoms of infection and know to notify the physician if they occur. Pressure garments may need to be worn for up to two years. A high-protein diet rather than a high-carbohydrate diet is recommended to promote healing and recovery. Cold packs can damage new skin, so they would not be appropriate.

An occupational health nurse arrives at the scene where a client suffered a burn from a chemical splash. What is the priority intervention? Cover the client with a blanket. Apply gloves and remove the client from the scene. Flush the area with copious amounts of water. Call 911.

Flush with water The priority is to flush with water to neutralize the chemicals and to decrease a heat reaction. This also decreases the chemical contact time, which is directly related to the degree of injury. It is important to call 911 after beginning the flush of the affected area, because the client has other needs that cannot be managed at the scene. Covering the client or removal from the area will not stop the burn process, so the priority action is to flush the burned area.

What assessment data would lead the nurse to suspect that an inhalation injury may have occurred in a client with a severe burn? (Select all that apply.) Singed hair and eyebrows Decreased level of consciousness Decreased sputum production Excessive thirst Hoarse voice

Singed hair and eyebrows Decreased sputum production Hoarse voice

There has been a fire in an apartment building. All residents have been evacuated, but many are burned. Which clients should be transported to a burn center for treatment? select all a. An 8 year old with 3rd degree burns over 10% of his body b. A 20 year old who inhaled the smoke of the fire c. a 50 year old diabetic with first and second degree burns on his left forearm (about 5% of body surface) d. A 30 year old with 2nd degree burns on the back of his left leg e. A 40 year old with second degree burns on his right arm (about 10% of his body surface).

a. b. c. Children under age 10 Adults over age 50 with 2nd and 3rd degree burns on 10% or greater of BSA. Clients between ages 11-49 with 2nd and 3rd degree burns over 20% of their BSA. Clients of any age with 3rd degree burns on more than 5% of their BSA. Clients with smoke inhalation Clients with DM, heart, or kidney disease

During the emergent phase of burn injury, which of the following indicates that the client is requiring additional volume with fluid resuscitation? a. serum creatinine level of 2.5 mg/dL b. little fluctuation in daily weight c. hourly urine output of 60 mL d. serum albumin level of 3.8

a. fluid shifting into the interstitial space causes intravascular volume depletion and decreased perfusion to the kidneys. This would result in an increase in serum creatinine.

The nurse explains to the family that he needs to have an escharotomy. The nurse includes which of the following statements in the explanation? a. it is done to prevent ischemia and necrosis b. it is exactly the same as a faciotomy c. it is done to promote drainage of edema fluid d. it is only done on extremities

a. prevents ischemia and necrosis

A nurse is planning care for a client who has burn injuries. Which of the following interventions should be included in the plan of care? select all a. use standard precautions when performing care b. encourage fresh veggies c. increase protein intake d. 3,000 calories per day e. restrict fresh flowers in the room

a. standard precautions to decrease risk of infection c. increase protein to promote wound healing d. flowers cary bacteria, increases risk for infection b. veggies have bacteria, increases risk for infection d. 5,000 calories per day

In the acute phase of burn injury, which pain medication would most likely be given to the client to decrease the perception of the pain? a. oral OTC analgesics b. IV opioids c. IM opiods d. Oral antianxiety agents

b. IV opiods client will be in severe pain

Which of the following clients with burns will most likely require an endotracheal or tracheostomy tube? a. electrical burns of the hands and arms causing arrhythmias b. thermal burns to the head, face, and airway resulting in hypoxia c. chemical burn on the chest and abdomen d. secondhand smoke inhalation

b. Tracheostomy or endotracheal intubation is anticipated with significant thermal and smoke inhalation burns occur.

The nurse in the immediate care clinic is assessing an 80 year old client who lives with his son's family and has scald burns on his hands and both forearms (first and second degree burns on 10% of his body). What should the nurse do first? a. clean the wounds with warm water b. apply antibiotic cream c. refer the client to a burn center d. cover the burns with a sterile dressing

c. refer the client to a burn center The client's age and the extent of the burns require care by a burn team and the client meets triage criteria for referral to a burn center. Because of the age of the client and the extent of the burns, the nurse should not treat the burn. Scald burns are not at high risk for injection and do not need to be cleaned, covered, or treated with antibiotic cream at this time.

A nurse is preparing to administer fentanyl to a client who was admitted 24 hours ago with deep partial thickness and full thickness burns over 60% of his body. The nurse should plan to use which of the following routes to administer the medication. a. subcutaneous b. IM c. IV d. transdermal

c. IV provides the most rapid pain relief.