Burns Iggy NCLEX

A client with burns has developed sepsis. Which sign or symptom in the client indicates fungal infection?

Occasional diarrhea

A client with a burn injury due to a house fire is admitted to the burn unit. The client's family asks the nurse why the client received a tetanus toxoid injection on admission. What is the nurse's best response to the client's family member?

"Burn wound conditions promote the growth of Clostridium tetani."

The nurse is caring for a client who has a severe burn injury and is receiving fluid resuscitation. The nurse should assess which laboratory findings to determine the client's response to the therapy?

*Serum creatinine levels*Blood urea nitrogen levels

A client's jeans caught on fire while camping, inflicting deep partial-thickness burns to the anterior and posterior surface of both legs. Using the rule of nines, what percent body surface area does the nurse estimate the client's burn to be? 1. 9% 2. 18% 3. 36% 4. 40%

36% - Using the rule of nines, burns to the anterior and posterior surface of both legs would be about 36% of total body surface area. Each leg is a total of 18%, with each anterior surface being 9%, and each posterior surface being 9%.

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%.

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 nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy? A) Return of distal pulses B) Brisk bleeding from the site C) Decreasing edema formation D) Formation of granulation tissue

A) Return of distal pulses

A nurse on a burn unit is caring for a patient in the acute phase of burn care. While performing an assessment during this phase of burn care, the nurse recognizes that airway obstruction related to upper airway edema may occur up to how long after the burn injury? A)2 days B)3 days C)5 days D)1 week

A)2 days

A patient who is in the acute phase of recovery from a burn injury has yet to experience adequate pain control. What pain management strategy is most likely to meet this patients needs? A)A patient-controlled analgesia (PCA) system B)Oral opioids supplemented by NSAIDs C)Distraction and relaxation techniques supplemented by NSAIDs D)A combination of benzodiazepines and topical anesthetics

A)A patient-controlled analgesia (PCA) system

A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurses immediate, priority concern when planning this patients care? A)Fluid status B)Risk of infection C)Nutritional status D)Psychosocial coping

A)Fluid status

A patient in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the patients laboratory studies, the nurse will expect the results to indicate what? A)Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis B)Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis C)Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis D)Hypokalemia, hyponatremia, elevated hematocrit, and metabolic alkalosis

A)Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis

A patient is admitted to the burn unit after being transported from a facility 1000 miles away. The patient has burns to the groin area and circumferential burns to both upper thighs. When assessing the patients legs distal to the wound site, the nurse should be cognizant of the risk of what complication? A)Ischemia B)Referred pain C)Cellulitis D)Venous thromboembolism (VTE)

A)Ischemia

A nurse is caring for a patient in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values? A)Sodium deficit B)Decreased prothrombin time (PT) C)Potassium deficit D)Decreased hematocrit

A)Sodium deficit

When teaching fire safety to parents at a school function, which advice does the school nurse offer about the placement of smoke and carbon monoxide detectors? A. "Every bedroom should have a separate smoke detector." B. "Every room in the house should have a smoke detector." C. "If you have a smoke detector, you don't need a carbon monoxide detector." D. "The kitchen and the bedrooms are the only rooms that need smoke detectors."

A. "Every bedroom should have a separate smoke detector." Teach all people to use home smoke detectors and carbon monoxide detectors and to ensure these are in good working order. The number of detectors needed depends on the size of the home. Recommendations are that each bedroom has a separate smoke detector, there should be at least one detector in the hallway of each story, and at least one detector is needed for the kitchen, each stairwell, and each home entrance. Carbon monoxide detectors are instrumental in picking up other types of carbon monoxide gas, such as from a defective heating unit.

What is the best method to prevent autocontamination for a client with burns? A. Change gloves when handling wounds on different areas of the body. B. Ensure that the client is in isolation therapy. C. Restrict visitors. D. Watch for early signs of infection.

A. Change gloves when handling wounds on different areas of the body. Gloves should be changed when wounds on different areas of the body are handled and between handling old and new dressings. Isolation therapy methods and restricting visitors are used to prevent cross-contamination, not autocontamination. Watching for early signs of infection does not prevent contamination.

Which factors indicate that a client's burn wounds are becoming infected? (Select all that apply.) A. Dry, crusty granulation tissue B. Elevated blood pressure C. Hypoglycemia D. Edema of the skin around the wound E. Tachycardia

A. Dry, crusty granulation tissue D. Edema of the skin around the wound E. Tachycardia Pale, boggy, dry, or crusted granulation tissue is a sign of infection, as is swelling or edema of the skin around the wound. Tachycardia is a systemic sign of infection. Hypotension, not elevated blood pressure, and hyperglycemia, not hypoglycemia, are systemic signs of infection.

To position a client's burned upper extremities appropriately, how does the nurse position the client's elbow? A. In a neutral position B. In a position of comfort C. Slightly flexed D. Slightly hyperextended

A. In a neutral position The neutral (extended) position is the correct placement of the elbow to prevent contracture development. Placing the elbow in a position of comfort is not the best placement because the client then usually wants to flex the joint, which increases the risk for contracture development. The slightly flexed position increases the risk for contracture development. The slightly hyperextended position is not indicated and can be painful.

A newly admitted client has deep partial-thickness burns. The nurse expects to see which clinical manifestations? A. Painful red and white wounds B. Painless, brownish yellow eschar C. Painful reddened blisters D. Painless black skin with eschar

A. Painful red and white wounds A painful red and white wound bed characterizes deep partial-thickness burns; blisters are rare. Painless, brownish yellow eschar characterizes a full-thickness burn. A painful reddened blister is seen with a superficial partial-thickness burn. Painless black skin with eschar is seen in a deep full-thickness burn.

An older client has suffered a 45% body surface area burn from a house fire. Which complication is the client at greater risk of developing because of age-related changes?

Acute kidney injury

The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Base on this level, the nurse would anticipate noting which sign in the client? A) Coma B) Flushing C) Dizziness D) Tachycardia

B) Flushing

The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide most reliable indicator for determining the adequacy? A) vital signs B) UOP C) Mental status D) Peripheral pulses

B) UOP

Which action by the nurse changing the dressings on the client who has burns on the right arm, the left arm, and the upper chest is most effective at preventing auto-contamination? A. Changing gloves after cleaning and dressing one wound area before cleaning and dressing the next wound area. B. Using sterile gloves to remove the old dressings and changing to fresh sterile gloves before applying the new dressings. C. Ensuring that the blood pressure cuff used on another client is thoroughly cleaned before using it on this client. D. Warning the client's family not to bring fresh fruit and vegetables or house plants into the client's environment.

Answer: A Rationale: Auto-contamination is the movement of organisms from one body area on a client to another body area. The use of sterile versus clean gloves for routine wound care varies by agency and is a matter of debate. Regardless of sterility, change gloves when handling wounds on different areas of the body and between handling old and new dressings. So, if the nurse changed to fresh gloves after removing old dressings but kept the fresh gloves on while dressing all the burn wound areas, he or she greatly increases the risk for translocating organisms from one burn wound to another, resulting in auto-contamination. Responses C and D address cross-contamination that occurs between people.

Which client response does the nurse interpret as an indication of fluid resuscitation adequacy? A. Decreasing pulse pressure B. Decreasing urine specific gravity C. Decreasing core body temperature D. Increasing respiratory rate and depth

Answer: B Rationale: Urine output is the most sensitive noninvasive measure of fluid resuscitation adequacy. An increase in urine output is a positive sign; however, so is a decreasing urine specific gravity. As urine output increases, the concentration of the urine decreases, leading to a decreased urine specific gravity. A decreasing pulse pressure often indicates a fall in systolic pressure, which would not indicate fluid resuscitation adequacy. A decreasing core body temperature is related to changes in the inflammatory response or metabolism and not an indication of fluid resuscitation adequacy. An increasing respiratory rate could indicate pulmonary edema but not fluid resuscitation adequacy. The increased respiratory depth may indicate other positive changes but not adequacy of fluid resuscitation.

A client with a burn injury due to a house fire is admitted to the burn unit. The client's family asks the nurse why the client received a tetanus toxoid injection on admission. What is the nurse's best response to the client's family member? A. "The last tetanus injection was less than 5 years ago." B. "Burn wound conditions promote the growth of Clostridium tetani." C. "The wood in the fire had many nails, which penetrated the skin." D. "The injection was prescribed to prevent infection from Pseudomonas."

B. "Burn wound conditions promote the growth of Clostridium tetani." Burn wound conditions promote the growth of Clostridium tetani, and all burn clients are at risk for this dangerous infection. Tetanus toxoid enhances acquired immunity to C. tetani, so this agent is routinely given when the client is admitted to the hospital. Regardless of when the last tetanus injection is given, it is still given on admission to prevent C. tetani. The fact that there were many nails in the wood in the fire is irrelevant. Tetanus toxoid injection does not prevent Pseudomonas infection.

The nurse is caring for a client with burns to the face. Which statement by the client requires further evaluation by the nurse? A. "I am getting used to looking at myself." B. "I don't know what I will do when people stare at me." C. "I know that I will never look the way I used to, even after the scars heal." D. "My spouse does not stare at the scars as much now as in the beginning."

B. "I don't know what I will do when people stare at me." The statement about not knowing what to do when people stare indicates that the client is not coping effectively; the nurse should assist the client in exploring coping techniques. Visits from friends and short public appearances before discharge may help the client begin adjusting to this problem. The statement that the client is getting used to looking at himself or herself, the realization that he or she will always look different than before, and stating that the client's spouse doesn't stare at the scars as much all indicate that the client is coping effectively. Community reintegration programs can assist the psychosocial and physical recovery of the client with serious burns.

A client is in the resuscitation phase of burn injury. Which route does the nurse use to administer pain medication to the client? A. Intramuscular B. Intravenous C. Sublingual D. Topical

B. Intravenous During the resuscitation phase, the IV route is used for giving opioid drugs because of problems with absorption from the muscle and stomach. When these agents are given by the intramuscular or subcutaneous route, they remain in the tissue spaces and do not relieve pain. In addition, when edema is present, all doses are rapidly absorbed at once when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics. The sublingual route may not be effective, and because the skin is too damaged, the topical route is not indicated for administering drugs to the client in the resuscitation phase of burn injury.

Several clients have been brought to the emergency department after an office building fire. Which client is at greatest risk for inhalation injury? A. Middle-aged adult who is frantically explaining to the nurse what happened B. Young adult who suffered burn injuries in a closed space C. Adult with burns to the extremities D. Older adult with thick, tan-colored sputum

B. Young adult who suffered burn injuries in a closed space The client who suffered burn injuries in a closed space is at greatest risk for inhalation injury because the client breathed a greater concentration of confined smoke. Clients who experienced a fire typically have some type of respiratory distress. However, the client talking without difficulty demonstrates minimal respiratory distress. Extensive burns to the hands and face, not the extremities, would be a greater risk. Sputum would be carbonaceous, not tan, if the client had suffered inhalation injury.

A nurse is developing a care plan for a patient with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. What is the best rationale for this intervention? A)To prevent neuropathies B)To prevent wound breakdown C)To prevent contractures D)To prevent heterotopic ossification

C)To prevent contractures

In assessing a client in the rehabilitative phase of burn therapy, which priority problem does the nurse anticipate? A. Intense pain B. Potential for inadequate oxygenation C. Reduced self-image D. Potential for infection

C. Reduced self-image In the rehabilitative phase of burn therapy, the client is discharged and his or her life is not the same. A priority problem of reduced self-image is expected. Intense pain and potential for inadequate oxygenation are relevant in the resuscitation phase of burn injury. Potential for infection is relevant in the acute phase of burn injury.

Which clinical manifestation is indicative of wound healing for a client in the acute phase of burn injury? A. Pale, boggy, dry, or crusted granulation tissue B. Increasing wound drainage C. Scar tissue formation D. Sloughing of grafts

C. Scar tissue formation Indicators of wound healing include the presence of granulation, re-epithelialization, and scar tissue formation. Pale, boggy, dry, or crusted granulation tissue is indicative of infection, as are increasing wound drainage and sloughing of grafts.

A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for this client? A) 100% O2 via an arousal mask B) Oxygen via nasal cannula 6L/minute C) Oxygen via nasal cannula at 15L/minute D) 100% Oxygen via a tight-fitting NRB face mask

D) 100% Oxygen via a tight-fitting NRB face mask

A patient arrives in the emergency department after being burned in a house fire. The patients burns cover the face and the left forearm. What extent of burns does the patient most likely have? A)13% B)25% C)9% D)18%

D)18%

A patient is brought to the ED by paramedics, who report that the patient has partial-thickness burns on the chest and legs. The patient has also suffered smoke inhalation. What is the priority in the care of a patient who has been burned and suffered smoke inhalation? A)Pain B)Fluid balance C)Anxiety and fear D)Airway management

D)Airway management

The nurse caring for a patient who is recovering from full-thickness burns is aware of the patients risk for contracture and hypertrophic scarring. How can the nurse best mitigate this risk? A)Apply skin emollients as ordered after granulation has occurred. B)Keep injured areas immobilized whenever possible to promote healing. C)Administer oral or IV corticosteroids as ordered. D)Encourage physical activity and range of motion exercises.

D)Encourage physical activity and range of motion exercises.

A patient is brought to the emergency department from the site of a chemical fire, where he suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the patients arm? A)Superficial partial-thickness B)Deep partial-thickness C)Full partial-thickness D)Full-thickness

D)Full-thickness

A nurse is caring for a patient with burns who is in the later stages of the acute phase of recovery. The plan of nursing care should include which of the following nursing actions? A)Maintenance of bed rest to aid healing B)Choosing appropriate splints and functional devices C)Administration of beta adrenergic blockers D)Prevention of venous thromboembolism

D)Prevention of venous thromboembolism

An occupational health nurse is called to the floor of a factory where a worker has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to cool the burn. How should the nurse cool the burn? A)Apply ice to the site of the burn for 5 to 10 minutes. B)Wrap the patients affected extremity in ice until help arrives. C)Apply an oil-based substance or butter to the burned area until help arrives. D)Wrap cool towels around the affected extremity intermittently.

D)Wrap cool towels around the affected extremity intermittently.

When delegating care for clients on the burn unit, which client does the charge nurse assign to an RN who has floated to the burn unit from the intensive care unit? A. Burn unit client who is being discharged after 6 weeks and needs teaching about wound care B. Recently admitted client with a high-voltage electrical burn C. A client who has a 25% total body surface area (TBSA) burn injury, for whom daily wound débridement has been prescribed D. Client receiving IV lactated Ringer's solution at 150 mL/hr

D. Client receiving IV lactated Ringer's solution at 150 mL/hr An RN float nurse will be familiar with administration of IV fluids and with signs of fluid overload, such as shortness of breath, and so could be assigned to the client receiving IV lactated Ringer's solution at 150 mL/hr. The client needing teaching about wound care, the client with a high-voltage electrical burn, and the client with a 25% TBSA burn injury all require specialized knowledge about burn injuries and should be assigned to RNs who have experience caring for clients with burn injuries.

A client is in the acute phase of burn injury. For which action does the nurse decide to coordinate with the registered dietitian? A. Discouraging having food brought in from the client's favorite restaurant B. Providing more palatable choices for the client C. Helping the client lose weight D. Planning additions to the standard nutritional pattern

D. Planning additions to the standard nutritional pattern Nutritional requirements for the client with a large burn area can exceed 5000 kcal/day. In addition to a high calorie intake, the burn client requires a diet high in protein for wound healing. Consultation with the dietitian is required to help the client achieve the correct nutritional balance. It is fine for the client with a burn injury to have food brought in from the outside. The hospital kitchen can be consulted to see what other food options may be available to the client. It is not therapeutic for the client with burn injury to lose weight.

Which dietary guideline must be followed for a client with a large burn area?

Feeding can be started within 4 hours of fluid resuscitation.

Which is the priority nursing intervention for maintaining mobility in a client with burns to the head and neck? 1. Maintain the client in a supine position for several hours a day. 2. Do not allow the use of pillows under the head or neck. 3. Encourage the client to logroll during position changes. 4. Use foam wedges to maintain trunk alignment.

Do not allow the use of pillows under the head or neck. - Maintaining optimal mobility is essential to the recovery process of the client with burns. Correct positioning to reduce the development of contractures is an important nursing intervention. Therefore, for clients with burn injuries to the head and neck, pillows should not be allowed. Supine positioning and logrolling will assist with clients who have burns to the chest and abdomen. Foam wedges are often used to maintain hip alignment.

Which assessment does the nurse perform first on a client who has been admitted after an electrical injury with contact sites on the right hand and left foot?

Electrocardiography

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.

A client with an electrical burn is being resuscitated with fluids. The nurse reports a decrease in urine output from 50 mL/hr to 15 mL/hr. Which order does the nurse question?

Furosemide 40 mg IV

To position a client's burned upper extremities appropriately, how does the nurse position the client's elbow?

In a neutral position

Which alteration observed in a client rescued from a fire indicates pulmonary injury?

Inability to swallow fluids

During the resuscitation postburn phase, which route is used to administer morphine for pain relief?

Intravenous

A client's burn injury was caused by a gasoline-fueled explosion. Which laboratory result does the nurse monitor closely for possible signs of organ injury?

Liver function tests

Which category of burn injury reflects deep partial-thickness burns affecting 20% of the total body surface area (TBSA)? 1. Moderate burn 2. Major burn 3. Minor burn 4. Severe burn

Moderate burn - Deep partial-thickness burns affecting 15% to 25% TBSA are classified as moderate burns. Partial-thickness burns affecting more than 25% of TBSA are classified as major burns. Deep partial-thickness burns affecting less than 15% of TBSA are considered minor burns. Burns are categorized as three types: major, minor, and moderate; there is no "severe" burn category.

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.

Which clinical manifestation is indicative of wound healing for a client in the acute phase of burn injury?

Scar tissue formation

A client who was rescued from an explosion is provided fluid resuscitation. Which factor should be assessed in the client after providing fluid resuscitation? 1. Serum sodium levels 2. Hemoglobin levels 3. Alanine aminotransferase 4. Serum cholesterol levels

Serum sodium levels - Renal failure is caused due to the accumulation of large amounts of proteins and myoglobin in the kidneys as a result of muscle damage. Fluid resuscitation must be provided to the client in order to maintain a rate of 30 to 50 mL of urine output. Serum sodium levels, serum creatinine levels, and specific gravity of the urine must be monitored every hour after providing fluid resuscitation to the client—it helps to assess kidney function. Hemoglobin levels can be monitored in case of anemia; hemoglobin levels are not an indicator of kidney function. Alanine aminotransferase is an enzyme that is secreted by the liver and is an indicator of hepatic functioning.

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

A client arrives in the emergency department with burns as a result of spilling boiling water while cooking. Which assessment finding of the burned areas on the tops of both hands and chest does the nurse use as a basis to document a probable full-thickness injury?

Thrombosed blood vessels are visible beneath the skin surface.

How does the nurse determine accurate calorie requirements for a client with burns?

Using indirect calorimetry

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

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.

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.

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

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.

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

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.

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.

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.

An emergency department nurse learns from the paramedics that they are transporting a patient who has suffered injury from a scald from a hot kettle. What variables will the nurse consider when determining the depth of burn? A)The causative agent B)The patients preinjury health status C)The patients prognosis for recovery D)The circumstances of the accident

A)The causative agent

A client with burn injuries states, "I feel so helpless." Which nursing intervention is most helpful for this client? A. Encouraging participation in wound care B. Encouraging visitors C. Reassuring the client that he or she will be fine D. Telling the client that these feelings are normal

A. Encouraging participation in wound care Encouraging participation in wound care will offer the client some sense of control. Encouraging visitors may be a good distraction, but will not help the client achieve a sense of control. Reassuring the client that he or she will be fine is neither helpful nor therapeutic. Telling the client that his or her feelings are normal may be reassuring, but does not address the client's issue of feeling helpless.

A client with partial-thickness burns of the face and chest caused by a campfire is admitted to the burn unit. The nurse plans to carry out which health care provider request first? A. Give oxygen per facemask. B. Infuse lactated Ringer's solution at 150 mL/hr. C. Give morphine sulfate 4 to 10 mg IV for pain control. D. Insert a 14 Fr retention catheter.

A. Give oxygen per facemask. Facial burns are frequently associated with upper airway inflammation. Administration of oxygen will assist in maintaining the client's tissue oxygenation at an optimal level. Although fluid hydration and pain control are important, the nurse's first priority is the client's airway. Monitoring output is important, but the nurse's first priority is the client's airway.

The nurse is reviewing the health history for an older adult client recently admitted to the burn unit with severe burns to the upper body from a house fire. The nurse plans to contact the health care provider if the client's history reveals which condition? A. Heart failure B. Diverticulitis C. Hypertension D. Emphysema

A. Heart failure A client's health history, including any pre-existing illnesses, must be known for appropriate management. Obtain specific information about the client's history of cardiac or kidney problems, chronic alcoholism, substance abuse, and diabetes mellitus. Any of these problems can influence fluid resuscitation. The stress of a burn injury can make a mild disease process worsen. In older clients, especially those with cardiac disease, a complicating factor in fluid resuscitation may be heart failure or myocardial infarction. Diverticulitis, hypertension and emphysema are important to be aware of in guiding treatment options. However, heart failure is the main concern when attempting to optimize this older client's fluid resuscitation.

The nurse is caring for a client with a burn injury who is receiving silver sulfadiazine (Silvadene) to the burn wounds. Which best describes the goal of topical antimicrobials? A. Reduction of bacterial growth in the wound and prevention of systemic sepsis B. Prevention of cross-contamination from other clients in the unit C. Enhanced cell growth D. Reduced need for a skin graft

A. Reduction of bacterial growth in the wound and prevention of systemic sepsis Topical antimicrobials such as silver sulfadiazine are an important intervention for infection prevention in burn wounds. Topical antimicrobials such as silver sulfadiazine do not prevent cross-contamination from other clients in the unit. They do not enhance cell growth, nor do they minimize the need the need for a skin graft.

An escharotomy must be performed in a client admitted for burns. Which statement accurately describes this procedure? 1. An incision is made through the burn eschar. 2. Anesthesia is administered to the client for pain. 3. Analgesia is not administered with this procedure. 4. The procedure is performed in the surgical suite.

An incision is made through the burn eschar. - Escharotomy is a surgical procedure that is performed to treat inadequate tissue perfusion in the client with severe burns. In this procedure, an incision is made through the burn eschar. It helps to relive the pressure caused due to fluid accumulation near the chest and improves circulation. It is not necessary to administer anesthesia to the client as the nerve endings are destroyed due to the injury. The client is given sedation and analgesia to reduce anxiety. Although escharotomy is a surgical procedure, it is often performed in a treatment room.

For which type of burn injury is it most important for the nurse to assess the client for a respiratory injury? A. Hot liquid scald burn B. Liquid chemical burn C. Electrical burn D. Dry heat burn

Answer: D Rationale: Direct injury to the lung from contact with flames, scalding hot liquids, liquid chemicals, or electrical current rarely occurs. Rather, respiratory problems are caused by superheated air, steam, toxic fumes, or smoke. Although it is possible for an electric current to pass through the lungs, it seldom causes injury.

A client with burns to the face, neck, upper body, and hands from a house fire starts wheezing on exhalation and reports difficulty swallowing about 4 hours after the injury. What is the nurse's best first action? 1. Ensure that the client remains NPO. 2. Apply oxygen and notify the Rapid Response Team. 3. Slow the IV infusion rate. 4. Raise the head of the bed.

Apply oxygen and notify the Rapid Response Team. - The client is at high risk for an inhalation injury from the circumstances of the burn (enclosed space and burns to the face, neck, upper body, and hands). The wheezing and difficulty swallowing indicate possible pulmonary injury and oral and throat swelling. This client is in danger of losing a patent airway and needs emergency intubation immediately.

A client with 32% total body surface area burns has a hematocrit of 54% 10 hours after the burn injury and 8 hours after fluid resuscitation was started. What is the nurse's best action? 1. Assess the client's blood pressure and urine output. 2. Notify the health care provider immediately. 3. Evaluate the client's electrocardiogram for dysrhythmias. 4. Increase the IV infusion rate.

Assess the client's blood pressure and urine output. - The massive fluid shift causes hemoconcentration of the cells in the blood. The first action needed is to evaluate the adequacy of the fluid resuscitation by assessing the client's blood pressure and hourly urine output. If fluid resuscitation is adequate, no other action is needed. If blood pressure and urine output indicate fluid resuscitation at the current rate is not adequate, the health care provider should be called and resuscitation volumes may be increased.

A client was brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to get out of a car fire. The nurse should implement which nursing actions for this client? A) Restrict fluids B) Assess for airway patency C) Administer oxygen as prescribed D) Place a cooling blanket on the client E) Elevate extremities if no fractures are present F) Prepare to give oral pain medication as prescribed

B) Assess for airway patency C) Administer oxygen as prescribed E) Elevate extremities if no fractures are present

A patient has experienced an electrical burn and has developed thick eschar over the burn site. Which of the following topical antibacterial agents will the nurse expect the physician to order for the wound? A)Silver sulfadiazine 1% (Silvadene) water-soluble cream B)Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream C)Silver nitrate 0.5% aqueous solution D)Acticoat

B)Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream

The nurse on a burn unit has just received change-of-shift report about these clients. Which client does the nurse assess first? A. Adult client admitted a week ago with deep partial-thickness burns over 35% of the body who is reporting pain B. Firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers, "I can't catch my breath!" C. An electrician who suffered external burn injuries a month ago and is asking the nurse to contact the health care provider immediately about discharge plans D. Older adult client admitted yesterday with partial- and full-thickness burns over 40% of the body who is receiving IV fluids at 250 mL/hr

B. Firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers, "I can't catch my breath!" Smoke inhalation and facial burns are associated with airway inflammation and obstruction; the client with difficulty breathing needs immediate assessment and intervention. Although the client admitted a week ago with deep partial-thickness burns is reporting pain, this client does not require immediate assessment. The electrician who suffered burn injuries a month ago is stable and has been in the burn unit for a month, so the client's condition does not warrant that the nurse should assess this client first. The older adult client admitted yesterday with burns over 40% of the body is stable; he is receiving IV fluids and does not need to be assessed first.

Which wound assessment characteristics suggest a superficial partial-thickness burn injury? A. Black-brown coloration B. Painful C. Moderate to severe edema D. Absence of blisters

B. Painful Characteristics of a superficial partial-thickness burn injury include pink to red coloration, mild to moderate edema, pain, and blisters. A black-brown coloration is more suggestive of full-thickness burn injury. Moderate to severe edema and absence of blisters may be present with deep partial-thickness to full-thickness burn injuries.

A nursing student is caring for a client with open-wound burns. Which nursing interventions does the nursing student provide for this client? (Select all that apply.) A. Provides cushions and rugs for comfort B. Performs frequent handwashing C. Places plants in the client's room D. Performs gloved dressing changes E. Uses disposable dishes

B. Performs frequent handwashing D. Performs gloved dressing changes E. Uses disposable dishes Handwashing is the most effective technique for preventing infection. Gloves should be worn when changing dressings to reduce the risk for infection. Equipment is not shared with other clients to prevent the risk for infection. Disposable items (e.g., pillows, dishes) are used as much as possible. Cushions and rugs are difficult to clean and may harbor organisms, and so are not provided. To avoid exposure to Pseudomonas, having plants or flowers in the room is prohibited.

An adult client was burned in an explosion. The burn initially affected the client's entire face. and the upper of of the anterior torso, and there were circumferential burns to the lower half of both arms. The clients clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would bet the extent of the burn injury? A) 18% B) 24% C) 36% D) 48%

C) 36%

A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50mm/Hg, a pulse rate of 110/beats per minute, and a urine output of 20ml over the past hour. The nurse reports the findings to the health care provider and anticipates which prescription? A) Transfusing 1 unit of packed RBCs B) Administering a diuretic to increase urine output C) Increasing the amount of IV fluid D) Changing the IV LR to 5% dextrose

C) Increasing the amount of IV fluid

The current phase of a patients treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the patient is in what phase of burn care? A)Emergent B)Immediate resuscitative C)Acute D)Rehabilitation

C)Acute

A patient has experienced burns to his upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action? A)Instruct the patient to keep the wound site in a dependent position. B)Administer PRN analgesia as ordered. C)Assess the patients peripheral pulses distal to the dressing. D)Assist with passive range of motion exercises to set the new dressing.

C)Assess the patients peripheral pulses distal to the dressing.

A patient experienced a 33% TBSA burn 72 hours ago. The nurse observes that the patients hourly urine output has been steadily increasing over the past 24 hours. How should the nurse best respond to this finding? A)Obtain an order to reduce the rate of the patients IV fluid infusion. B)Report the patients early signs of acute kidney injury (AKI). C)Recognize that the patient is experiencing an expected onset of diuresis. D)Administer sodium chloride as ordered to compensate for this fluid loss.

C)Recognize that the patient is experiencing an expected onset of diuresis.

The nurse is caring for a client with burns. Which question does the nurse ask the client and family to assess their coping strategies? A. "Do you support each other?" B. "How do you plan to manage this situation?" C. "How have you handled similar situations before?" D. "Would you like to see a counselor?"

C. "How have you handled similar situations before?" Asking how the client and family have handled similar situations in the past assesses whether the client's and the family's coping strategies may be effective. "Yes-or-no" questions such as "Do you support each other?" are not very effective in extrapolating helpful information. The client and family in this situation probably are overwhelmed and may not know how they will manage; asking them how they plan to manage the situation does not assess coping strategies. Asking the client and the family if they would like to see a counselor also does not assess their coping strategies.

A client who was the sole survivor of a house fire says, "I feel so guilty. Why did I survive?" What is the best response by the nurse? A. "Do you want to pray about it?" B. "I know, and you will have to learn to adapt to a new body image." C. "Tell me more." D. "There must be a reason."

C. "Tell me more." Asking the client to tell the nurse more encourages therapeutic grieving. Offering to pray with the client assumes that prayer is important to the client and does not allow for grieving; the nurse should never assume that the client is religious. The response, "I know, and you will have to learn to adapt to a new body image" only serves to add stress to the client's situation. The response, "There must be a reason" minimizes the grieving process by not allowing the client to express his or her concerns.

Which strategy does the nurse include when teaching a college student about fire prevention in the dormitory room? A. Use space heaters to reduce electrical costs. B. Check water temperature before bathing. C. Do not smoke in bed. D. Wear sunscreen.

C. Do not smoke in bed. Smoking in bed increases the risk for fire because the person could fall asleep. Use of space heaters may increase the risk for fire, especially if they are knocked over and left unattended. Checking water temperature does not prevent fires, but it should be checked if the client has reduced sensation in the hands or feet. Sunscreen is advised to prevent sunburn.

A client with burn injuries is being admitted. Which priority does the nurse anticipate within the first 24 hours? A. Range-of-motion exercises B. Emotional support C. Fluid resuscitation D. Sterile dressing changes

C. Fluid resuscitation The client will require fluid resuscitation because fluid does not stay in the vessels after a burn injury. Range-of-motion exercise is not the priority for this client. Although emotional support and sterile dressing changes are important, they are not the priority during the resuscitation phase of burn injury.

Which assessment is the nurse's highest priority in caring for a client in the acute phase of burn injury? A. Bowel sounds B. Muscle strength C. Signs of infection D. Urine output

C. Signs of infection The client with burn injury is at risk for infection as a result of open wounds and reduced immune function. Burn wound sepsis is a serious complication of burn injury, and infection is the leading cause of death during the acute phase of recovery. Assessing bowel sounds, assessing muscle strength, and assessing urine output are important but not the priority during the acute phase of burn injury.

Which assessment information about a 60-kg client admitted 12 hours ago with a full-thickness burn over 30% of the total body surface area is of greatest concern to the nurse? A. Bowel sounds are absent. B. The pulse oximetry level is 91%. C. The serum potassium level is 6.1 mEq/L. D. Urine output since admission is 370 mL.

C. The serum potassium level is 6.1 mEq/L. An elevated serum potassium level can cause cardiac dysrhythmias and arrest, and so is of the most concern. Absence of bowel sounds, a pulse oximetry level of 91%, and urine output of 370 mL since admission are normal findings during the resuscitation phase of burn injury.

The nurse is evaluating the effectiveness of fluid resuscitation for a client in the resuscitation phase of burn injury. Which finding does the nurse correlate with clinical improvement? A. Blood urea nitrogen (BUN), 36 mg/dL B. Creatinine, 2.8 mg/dL C. Urine output, 40 mL/hr D. Urine specific gravity, 1.042

C. Urine output, 40 mL/hr Fluid resuscitation is provided at the rate needed to maintain urine output at 30 to 50 mL/hr or 0.5 mL/kg/hr. A BUN of 36 mg/dL is above normal, a creatinine of 2.8 mg/dL is above normal, and a urine specific gravity of 1.042 is above normal.

What precautionary measure must individuals take to prevent fires? 1. While drinking alcohol, smoking must be done in an open area. 2. Space heaters must be placed on a cotton cloth. 3. Chimneys must be cleaned once in a year. 4. One smoke detector must be placed in the house.

Chimneys must be cleaned once in a year. - Chimneys must be cleaned once a year to avoid creosote accumulation, which is a highly flammable material. Clients must be advised not to smoke while drinking alcohol, as alcohol can cause drowsiness and a lit cigarette could be dropped. Clothing, bedding, and other materials should be kept away from space heaters. Smoke detectors must be placed in each bedroom and in stairwells.

When delegating care for clients on the burn unit, which client does the charge nurse assign to an RN who has floated to the burn unit from the intensive care unit? 1. Burn unit client who is being discharged after 6 weeks and needs teaching about wound care 2. Recently admitted client with a high-voltage electrical burn 3. A client who has a 25% total body surface area (TBSA) burn injury, for whom daily wound débridement has been prescribed 4. Client receiving IV lactated Ringer's solution at 150 mL/hr

Client receiving IV lactated Ringer's solution at 150 mL/hr - An RN float nurse will be familiar with administration of IV fluids and with signs of fluid overload, such as shortness of breath, so could be assigned to the client receiving IV lactated Ringer's solution at 150 mL/hr. The client needing teaching about wound care, the client with a high-voltage electrical burn, and the client with a 25% total body surface burn injury all require specialized knowledge about burn injuries and should be assigned to RNs who have experience caring for clients with burn injuries.

The client is a burn victim who is noted to have increasing edema and decreased urine output as a result of the inflammatory compensation response. What does the nurse do first? A. Administer a diuretic. B. Provide a fluid bolus. C. Recalculate fluid replacement based on time of hospital arrival. D. Titrate fluid replacement.

D. Titrate fluid replacement. The intravenous fluid rate should be adjusted on the basis of urine output plus serum electrolyte values (titration of fluids). A common mistake in treatment is giving diuretics to increase urine output. Giving a diuretic will actually decrease circulating volume and cardiac output by pulling fluid from the circulating blood volume to enhance diuresis. Fluid boluses are avoided because they increase capillary pressure and worsen edema. Fluid replacement formulas are calculated from the time of injury, not from the time of arrival at the hospital.

The nurse is reviewing a medication record for an older adult client recently admitted to the burn unit with severe burns to the upper body from a house fire. The nurse plans to contact the health care provider if the client is receiving which medication? 1. Furosemide (Lasix) 2. Digoxin (Lanoxin) 3. Dopamine (Inotropin) 4. Morphine sulfate

Furosemide (Lasix) - Furosemide, a diuretic, generally is not given to improve urine output for burn clients. Diuretics decrease circulating volume and cardiac output by pulling fluid from the circulating blood to enhance diuresis. This reduces blood flow to other vital organs. Digoxin may be used to strengthen the force of myocardial contractions in older adult clients. Dopamine may be given to increase cardiac output in older adult clients. Morphine sulfate may be indicated for pain management.

A client with partial-thickness burns of the face and chest caused by a campfire is admitted to the burn unit. The nurse plans to carry out which health care provider request first?

Give oxygen per nonrebreather mask at 100% Fio2.

The nurse is reviewing the orders for a client admitted with 25% body surface area burns. Which order does the nurse clarify with the health care provider?

Hold omeprazole (Prilosec)

Which electrolyte abnormality does the nurse anticipate during the resuscitation phase in a client with burn injury?

Hyperkalemia

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.

A client with full-thickness burns to the lower extremities has had emergent fasciotomies. What assessment parameter does the nurse monitor to evaluate the effectiveness of the fasciotomies? 1. Improved distal pulses 2. Reduced edema 3. Improved blood pressure 4. Reduced fluid resuscitation needs

Improved distal pulses - When edema is severe under the eschar of a full-thickness wound, blood flow to the area is compromised. Incisions, escharotomies, or fasciotomies are performed to relieve the growing pressure under the eschar. After the escharotomy or fasciotomy is performed, the assessment of improved perfusion is achieved by evaluating pulses distal to the procedure. Edema may not be reduced immediately due to inflammation from the incision. Blood pressure may be slightly elevated secondary to discomfort following the procedure. A fasciotomy does not necessarily indicate that fluid resuscitation will no longer be required.

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.

Which method must be employed during hydrotherapy for the debridement of a wound in the client with acid burns?

Nonviable tissue must be removed by forceps.

A client with burns to the face, neck, upper body, and hands from a house fire starts wheezing on exhalation and reports difficulty swallowing about 4 hours after the injury. What is the nurse's best first action?

Notify the Rapid Response Team.

A client receives a prescription for collagenase (Santyl) for treatment of burns. To decrease the risk of infection, the nurse expects what else to be included on the client's plan of care?

Polysporin powder

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 Curling'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.

The nurse is caring for a client with a burn injury who is receiving sulfadiazine (Silvadene) to the burn wounds. Which best describes the goal of topical antimicrobials?

Reduction of bacterial growth in the wound and prevention of systemic sepsis

Why is positive end-expiratory pressure (PEEP) provided to the clients with major burns? 1. To increase the lung volume 2. To decrease the exchange of gases 3. To increase the vascular supply 4. To increase the respiratory rate

To increase the lung volume - Clients with major burns have acute respiratory distress syndrome due to hypoxia. In end-expiratory pressure (PEEP), continuous positive pressure is applied in the alveoli and the airways to increase lung volume. It helps to increase oxygen permeability across the alveoli and capillaries. PEEP does not affect vascular supply, as it is an external pressure applied in the lung. PEEP is not used to increase respiratory rate.

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 placeFluid 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 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

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.

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 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

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 10Adults 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 inhalationClients with DM, heart, or kidney disease

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

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.

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.