burns

full thickness (third degree)

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?

27%

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

Fluid resuscitation

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

36%

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?

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

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.

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?

The early appearance of the burn injury may change.

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?

Instruct to pat and not scratch the areas.

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?

inflammatory

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

premedicating the client with an analgesic prior to application.

A client with a burn wound is prescribed mafenide acetate 5% twice daily. Nursing implications associated with this medication include

BUN: 28 mg/dL

A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern?

Dry and pale white.

A nurse helps a health care provider treat a full-thickness burn on a patient's hand. Prior to treatment, the nurse documents the appearance of the wound as:

Replace lost fluids and electrolytes.

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

wrap elastic bandages distally to proximally on dependent areas.

A nurse is caring for a client with skin grafts covering full-thickness burns on the arms and legs. During dressing changes, the nurse should:

The client's complete blood count readings reflect a reduced hematocrit.

A nurse is preparing a care plan for a client burned over 36% of his body 2 days ago. Which clinical manifestation indicates that the client has progressed into the intermediate phase of burn care?

The client's urinary output is 0.5 mL/kg/hour.

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?

Epidermis and a portion of deeper dermis.

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:

Hemodilution

A nurse provides care for a client with deep partial-thickness burns 48 hours after the burn. What would cause a reduced hematocrit in this client?

Full-thickness

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?

2 to 4 weeks

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?

36%

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?

pulmonary system

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

Zone of stasis

Following a burn, the nurse understands that the focused management of which burn zone is of greatest concern?

application of ice

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?

Hyperkalemia.

Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is:

hyperkalemia

Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is:

Mafenide (Sulfamylon)

In a client who has been burned, which medication should the nurse expect to use to prevent infection?

Applying knee splints

In a client with burns on the legs, which nursing intervention helps prevent contractures?

A urine output consistently above 40 ml/hour

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?

Hoarseness of the voice

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

Deep partial thickness

When the nurse learns that the client suffered injury from a flash flame, the nurse anticipates which depth of burn?

Lactated Ringer's (LR)

Which of the following is the preferred IV fluid for burn resuscitation?

Intestinal tract

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

Silver nitrate solution

Which of the following topical burn preparations act as wick for sodium and potassium?

Full-thickness

Which type of burn injury requires skin grafting?

Hyperkalemia

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?

Identification by the destruction of the dermis and epidermis

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?

Prodromal In this phase, symptoms present 48 to 72 hours after exposure and include fever, respiratory distress, and increased excitability for victims exposed to high doses of radiation. During the latent phase, symptoms include decreasing numbers of lymphocytes, leukocytes, thrombocytes, and red blood cells.

The nurse is caring for victims after a mass casualty incident with high-dosage radiation exposure. The victims are experiencing fever, respiratory distress, and increased excitability. The nurse documents that the victims are in which phase of radiation exposure?

A urinary output of 30 mL/hr

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?

Silver nitrate 0.5%

The nurse knows that which topical antibacterial agent does not penetrate eschar?

Liquid blood component is lost into extravascular space

The nurse understands that during the emergent/resuscitative phase of burn injury, hemoconcentration is due to which of the following?

Electrical burns usually follow an internal path.

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?

Compare the client's palm with the size of the burn wound

What quick assessment technique should the nurse use to assess the percentage of burn injury?

5 days

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

Place the client in a horizontal position. Roll the client in a blanket to smother the fire.

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.

Capillary leak

Burn shock is characterized by which of the following?

Capillary leak Burn shock is characterized by capillary leak, "third spacing" of fluid, severe hypovolemia, and decreased cardiac output (CO)

Burn shock is characterized by which of the following?

Skin grafting will be necessary.

The client is admitted with full-thickness burns to the forearm. Which is the most accurate interpretation made by the nurse?