Burns: Questions

Burns Should you remove adhered clothing?

No

A patient has a burn on the back of the torso that is extremely red and painful but no blisters are present. When you pressed on the skin it blanches. You document this as a: a. 1st degree (superficial) burn b. 2nd degree (partial-thickness) burn c. 3rd degree (full-thickness) burn d. 4th degree (deep full-thickness) burn

a RAT: These are the classic characteristics of a 1st degree, superficial burn.

You receive a patient who has experienced a burn on the right leg. You note the burn contains small blisters and is extremely pinkish red and shiny/moist. The patient reports severe pain. You document this burn as: a. 1st Degree (superficial) b. 2nd Degree (partial-thickness) c. 3rd Degree (full-thickness) d. 4th Degree (deep full-thickness)

b RAT: These are the classic characteristics of a 2nd degree (partial-thickness) burn.

Burns Name the 3 phases of burns

1. Emergent/Resuscitation/Shock 2. Acute/Diuretic 3. Rehabilitative/Recovery * Think EAR (Emergent, Acute, Rehabilitative, but know what else they are called as it comes in handy)

Burns How long does the fluid mobilization or diuretic phase of a burn last?

2 to 5 days

Burns When the burn patient is receiving patient care, when should pain medication be administered?

30 minutes before care

Burns Mafenide acetate (Sulfamylon) cream causes the patient to experience what?

A burning sensation

Burns In the Emergent/Resuscitation/Shock phase, fluid moves from the _____ to the _____ _____ .

Bloodstream Interstitial space

You are caring for a patient who sustained burns that are pink, moist, sensate, and blanching. Vital signs are: HR 150 bpm BP 90/30 Urine output: 15 mL/hr With whom will you collaborate to provide the highest quality interprofessional care for this patient?

Collaborate immediately with the healthcare provider, other nurses, pharmacist, and respiratory therapist; later, collaborate also with the case manager, social worker, psychologist, and spiritual leader of the patient's choice

Burns In the diuretic phase, K+ levels fall or rise?

Fall- remember diuresis always causes hypokalemia.

Burns If the MD orders 2,800 cc of fluid in the first 24 hours after a burn, how much is infused in the first eight hours.

Half (or 1,400 mL)

Burns What blood value will dictate IV flow rate?

Hematocrit (HCT)

Burns The burn patient will be on _____ urine output and daily ______.

Hourly, weight

Burns The Emergent/Resuscitation/Shock phase of the burn is potassium increased or decreased? Why?

Increased Cell damage- The K+ is released from the damaged cells.

You are caring for a patient who sustained burns that are pink, moist, sensate, and blanching. Vital signs are: HR 150 bpm BP 90/30 Urine output: 15 mL/hr How do you anticipate administering pain medication during the acute phase of burn injury?

Intravenously, because of problems with absorption from the muscle and the stomach.

Burns What is Curling's ulcer? Why do burn patients get it? What drug prevents it?

It is a stress GI ulcer You get it with any severe physical stress. Meds: H2 receptor antagonist (-tidine) Proton pump inhibitors, PPIs (-zole)

Burns What acid-base disorder is seen in the shock phase of a burn?

Metabolic acidosis

Burns What is the simple formula for calculating fluid replacement needs in the first 24 hours after a burn?

Parkland Formula 4 mL x TBSA% x Weight in kg

You are caring for a patient who sustained burns that are pink, moist, sensate, and blanching. Vital signs are: HR 150 bpm BP 90/30 Urine output: 15 mL/hr What degree burn does this patient have? Provide rationale.

Partial thickness. There is still a good blood supply to the wound resulting in the color pink and blanching. The nerve endings are exposed resulting in pain and indicating that the dermis is intact.

Burns The nutrient needed most for growth and repair of tissues is?

Protein

Burns If the nurse accidently runs the IVs at the shock phase rate during the diuretic phase the patient will experience ?

Pulmonary edema

Burns List characteristics of a 2nd degree burn:

Red in color Blisters present (vesicles) Painful Shiny, wet

Burns List characteristics of a 1st degree burn:

Red in color No blisters (vesicles) Painful

Burns Using the Rule of Nines, list what percentage the following areas of the body receive; Genitalia Head/neck Each Arm Each Leg Torso

Remember, these numbers are for one side of the body (front or back). If they have both anterior and posterior burns on an area, double the number. Genitalia: 1 % Head/neck: 4.5 % Arm: 4.5 % Leg: 9 % Torso: 18 %

Burns Silver nitrate cream can do what to the skin?

Stain the skin

Burns Which tetanus vaccine is given if the patient has NOT previously been vaccinated?

Tetanus antitoxin (or immune globulin)

Burns What is the only IM given to a burn patient?

Tetanus shot Give all other IV

Burns Which tetanus vaccine is given if the patient has previously been vaccinated?

Tetanus toxoid

Burns How will you know the patient has entered the fluid remobiliation or diuretic phase?

The urine output will increase.

Burns What is the Rule of Nines used for?

To estimate the percentage of total body surface area (TBSA) burned Is NOT used for children

Burns When using silver nitrate on a burn, the dressing must be kept ________

Wet

Burns List characteristics of a 3rd degree burn:

White in color Dry Skin is hard Waxy Less pain d/t nerve damage

Burns In the emergent phase do you cover burns? (in the field)

Yes, with anything clean and dry.

You are caring for a patient who sustained burns that are pink, moist, sensate, and blanching. Vital signs are: HR 150 bpm BP 90/30 Urine output: 15 mL/hr Based on the information provided, is the patient experiencing signs of shock?

Yes. Diaphoresis, tachycardia, hypotension, change in mental status, decreased capillary refill, and urine output less than 0.5 mL/kg per hour are all signs of shock.

After debridement of a burn wound, a human cadaver dressing is used to cover some of the wound. What is the term for this type of graft? a. Homograft b. Xenograft c. Autograft d. Isograft

a RAT: • Homograft (aka allograft) skin is processed by commercial skin banks. It is particularly useful in the coverage of surgically excised, deep partial-thickness and full-thickness wounds in extensive burns when available donor sites are limited. • Xenograft is from a variety of species, most notably pigs. It adheres less successfully than allograft because of a progressive, degenerative necrosis. • Autograft is a permanent graft of tissue obtained from undamaged areas of the patient's own body. • Isograft is a permanent graft of histocompatible tissue obtained from genetically identical individuals.

A newly admitted client has deep partial-thickness burns. The nurse expects to see which clinical manifestations? a. Red and white wounds with mild pain to palpation b. Painless, brownish yellow eschar c. Painful reddened blisters d. Black skin with eschar and no pain

a RAT: A red and white wound bed characterizes deep partial-thickness burns. Blisters are rare. Pain is less than with other types of burns because nerve endings are affected. 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.

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 RAT: Encouraging participation in wound care is most helpful in providing 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 burn client is receiving treatments of topical mafenide acetate to the site of injury. The nurse monitors the client, knowing that which finding indicates that a systemic effect has occurred? a. Hyperventilation b. Elevated BP c. Local rash at the burn site d. Local pain at the burn site

a RAT: Mafenide acetate is a carbonic anhydrase inhibitor and can suppress renal excretion, causing acidosis. Clients should be monitored for acid-base imbalance (hyperventilation). Elevated BP and local rash at the burn site describe local, rather then systemic effects. Elevated BP may be expected due to the pain from a burn injury.

As the nurse providing care to a patient who experienced a full-thickness electrical burn you know to monitor the patient's urine for: a. Hemoglobin and myoglobin b. Free iron and white blood cells c. Protein and red blood cells d. Potassium and Urea

a RAT: Patients who've experienced a severe electrical burn or full-thickness burns are at risk for acute kidney injury. This is because the muscles can experience damage from the electrical current leading them to release myoglobin. In addition, the red blood cells will release hemoglobin. These substances will collect in the kidneys leading to acute tubular necrosis (hence leading to AKI). Therefore, the nurse should monitor the patient's urine for these substances.

A 30 year old female patient has deep partial thickness burns on the front and back of the right and left leg, front of right arm, and anterior trunk. The patient weighs 63 kg. Use the Parkland Burn Formula: What is the flow rate during the FIRST 8 hours (mL/hr) based on the total you calculated? a. 921 mL/hr b. 938 mL/hr c. 158 mL/hr d. 789 mL/hr

a RAT: Remember: 1. Calculate the patient's TBSA 9+9+9+9+4.5+18 = 58.4% 2. Parkland Burn Formula is the amount of fluids a patient should receive in a 24 hour period = 4mL x TBSA x Weight in kg 4 x 58.5 x 63 = 14,742 mL 3. First 8 hours of fluid infusion is always half of the total amount of the solution 14,742 mL / 2 = 7,341 mL Hourly total = 7,341 mL / 8 hours = 921 mL/hr

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 RAT: The best description of the goal of topical antimicrobials such as silver sulfadiazine is that they help prevent infection 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.

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. Use sterile gloves when changing dressings.

a RAT: The best way to prevent autocontamination for a burn client is to change gloves when performing wound care on different areas of the body. Isolation therapy methods and restricting visitors are used to prevent cross-contamination, not autocontamination. Using sterile versus clean gloves is a matter of institutional preference and a topic of debate.

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 RAT: 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 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 RAT: The nurse needs to first administer oxygen per face mask to the client. 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 RAT: The nurse will contact the health care provider if the client's history reveals specific information about cardiac or kidney problems, chronic alcoholism, substance abuse, or diabetes mellitus. Any of these problems can influence fluid resuscitation. A client's health history, including any preexisting illnesses, must be known for appropriate management. 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.

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 RAT: The school nurse states that every bedroom needs to have a separate smoke detector. All people should be taught 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. Every room in the house does not need a 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. Each room that requires a smoke detector should also have a carbon monoxide detector. Carbon monoxide detectors are instrumental in picking up carbon monoxide gas emissions, such as from a defective heating unit.

A patient has full-thickness burns on the front and back of both arm and hands. It is nursing priority to: a. Elevate and extend the extremities b. Elevate and flex the extremities c. Keep extremities below heart level and extended d. Keep extremities level with the heart level and flexed

a RAT: This position will decrease edema, which will help prevent compartment syndrome.

What are some patient priorities during the Resuscitation/Emergent phase of burn management? Select all that apply a. Fluid volume b. Respiratory status c. Psychosocial d. Wound closure e. Nutrition

a, b RAT: This phase starts from the onset of the burn and ends with the restoration of capillary permeability. Wound closure, and nutrition would be during the acute phase, and would continue into the rehabilitative phase. Psychosocial would be in the rehab phase.

A 65 year old male patient has experienced full-thickness electrical burns on the legs and arms. As the nurse you know this patient is at risk for the following: Select all that apply a. Acute kidney injury b. Dysrhythmia c. Iceberg effect d. Hypernatremia e. Bone fractures f. Fluid volume overload

a, b, c, e RAT: Electric burns are due to an electrical current passing through the body that leads to damage to the skin but also the muscles and bones that are underneath the skin. The patient is at risk for AKI (acute kidney injury) because when the muscles become affected they release myoglobin and the red blood cells release hemoglobin in the blood, which can collect in the kidneys leading to injury. In addition, the heart's electrical system can become damaged leading to dysrhythmia. The iceberg effect can present as well because the extent of damage is not clearly visible on the skin (there can be severe damage underneath). In addition, if the electrical current is strong enough it can lead to bone fractures (specifically cervical spine injuries) due to the severe contraction of the muscles involved.

A patient arrives to the ER due to experiencing burns while in an enclosed warehouse. Which assessment findings below demonstrate the patient may have experienced an inhalation injury? Select all that apply a. Carbonaceous sputum b. Hair singeing on the head and nose c. Lhermitte's Sign d. Bright red lips e. Hoarse voice f. Tachycardia

a, b, d, e, f RAT: These are all signs of a possible inhalation injury. Bright red lips and tachycardia are present in carbon monoxide poisoning as well.

A patient arrives to the ER with full-thickness burns on the front and back of the torso and neck. The patient has no spinal injuries but is disoriented and coughing up black sooty sputum. Vital signs are: O2, 63% HR, 145 BP, 80/56 RR, 39. As the nurse you will: Select all that apply a. Place the patient in High Fowler's position. b. Prep the patient for escharotomy. c. Prep the patient for fasciotomy. d. Prep the patient for intubation. e. Place a pillow under the patient's neck. f. Obtain IV access at two sites. g. Restrict fluids.

a, b, d, f RAT: Location of the burns and the patient's presentation should be jumping out at you. The patient is at risk for circumferential burns due to the location of the burns and the depth (full-thickness....will have eschar present that will restrict circulation or here in this example the ability of the patient to breathe in and out). Based on the patient's VS, we see that the respiratory effort is compromised majorly AND that there is a risk of inhalation injury since the patient is coughing up black sooty sputum. Therefore, the nurse should place the patient in high Fowler's position to help with respiratory effort (unless contraindicated with spinal injuries), prep the patient for escharotomy (this will cut the eschar and help relieve pressure and allow for breathing) and prep for intubation to help with the respiratory distress. In addition, obtain IV access in at least two sites for fluid replacement....remember the first 24 hours after a burn a patient is at risk for hypovolemic shock.

Which nursing interventions decreases the risk for cross-contamination in the client with a severe burn injury? Select all that apply a. Place client in isolation. b. Encourage multiple visitors to support client. c. Ensure that no plants or flowers are in the client's room. d. Teach family members not to bring fresh fruits and vegetables to the client. e. Change gloves after cleaning and dressing of one wound area, before cleaning and dressing another.

a, c, d RAT: Placing the client away from other clients decreases the risk for cross-contamination. Plants, flowers, fruits, and vegetables can have bacteria or fungi that can introduce more contaminants into the environment; these should not be brought to the client's room. The number of visitors and frequency of visits should be limited due to the potential of bringing contaminants into the client's environment. Changing gloves decreases the risk of autocontamination, not cross-contamination.

You are about to provide care to a patient with severe burns. You will don: a. gloves b. goggles c. gown d. N-95 mask e. surgical mask f. shoe covers g. hair cover

a, c, e, f, g RAT: Before providing care to a patient with severe burns the nurse would want to wear protective isolation apparel like: gloves, gown, surgical mask, shoe covers, and hair cover. This protects the patient from potential infection.

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, d, e RAT: 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.

A 25 year old female patient has sustained burns to the back of the right arm, posterior trunk, front of the left leg, anterior head and neck, and perineum. Using the Rule of Nines, calculate the total body surface area (TBSA) percentage that is burned? a. 46% b. 37% c. 36% d. 28%

b RAT: back of right arm (4.5%) posterior trunk (18%) front of left leg (9%) anterior head and neck (4.5%) perineum (1%) Which equals 37%.

Burns- PEDS Tyler had his last diphtheria-tetanus-pertussis vaccine at age 18 months. Does he need tetanus prophylaxis now? a. Yes b. No

b RAT: A 3-year-old child is due for his next booster between ages 4 and 6 years and then again at age 11; therefore, a booster is not needed at this time. An injured adolescent or adult might be given a booster if it has been 5 years since his or her last booster. When given according to schedule, the diphtheria and tetanus vaccines provide protective antitoxin for 10 years or more.

A patient who experiences an alkali chemical burn is easier to treat because the skin will neutralize the chemical rather than with an acidic chemical burn. a. True b. False

b RAT: Alkali burns are harder to treat than acidic chemical burns because the skin will neutralize the acidic burn.

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 RAT: 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.

Which wound assessment characteristics suggest a superficial partial-thickness burn injury? a. Black-brown coloration b. Painful blisters c. Moderate to severe edema d. Absence of blisters

b RAT: 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 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 RAT: During the resuscitation phase, the intravenous (IV) route is used for giving opioid drugs because of problems with absorption from the muscle and stomach. When these agents (opioid drugs) 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.

A patient has an emergency escharotomy performed on the right leg. The patient has full-thickness circumferential burns on the leg. Which finding below demonstrates the procedure was successful? a. The patient can move the extremity. b. The right foot's capillary refill is less than 2 seconds. c. The patient reports a new sensation of extreme pain. d. The patient has a positive babinski reflex.

b RAT: Escharotomy is performed when a full-thickness burn, due to eschar (which is burned tissue that is hard), is compromising blood flow to the distal extremity. The eschar is cut and this relieves pressure and allows blood to flow to the extremity.

Burns- PEDS Tyler is a 3-year-old boy who weighs 15 kg (33 pounds). Fluid replacement therapy is considered minimally adequate when hourly urinary output is: a. 5 ml. b. 15 ml. c. 25 ml. d. 50 ml.

b RAT: Fluid replacement is maintained at a rate that will provide an hourly urinary output of 1 to 2 mL/kg for children weighing less than 30 kg (66 pounds). This would be a minimum urinary output of 15 mL/hr for a child weighing 15 kg (33 pounds).

You're assisting the nursing assistant with repositioning a patient with full-thickness burns on the neck. Which action by the nursing assistant requires you to intervene? a. The nursing assistant elevates the head of the bed above 30 degrees. b. The nursing assistant places a pillow under the patient's head. c. The nursing assistant places rolled towels under the patient's shoulders. d. The nursing assistant covers the patient with sterile linens.

b RAT: If a patient has severe burns to the neck (head as well) a pillow should NOT be used under the head because this can cause wound contractions. Instead rolled towels should be placed under the shoulders.

While collecting a medical history on a patient who experienced a severe burn, which statement by the patient's family member requires nursing intervention? a. "He takes medication for glaucoma". b. "I think it has been 10 years or more since he had a tetanus shot." c. "He was told he had COPD last year." d. "He smokes 2 packs of cigarettes a day."

b RAT: Patients who have had burns need a tetanus shot if they have not had a vaccine within the past 5 to 10 years.

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 RAT: 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.

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 RAT: 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.

Select the patient below who is at MOST risk for complications following a burn: a. A 42 year old male with partial-thickness burns on the front of the right and left arms and legs. b. A 25 year old female with partial-thickness burns on the front of the head and neck and front and back of the torso. c. A 36 year old male with full-thickness burns on the front of the left arm. d. A 10 year old with superficial burns on the right leg.

b RAT: The patient in option B has 40.5% TSBA burned (option A 27%, C: 4.5%, D: 9%). Remember that the higher the total of the body surface area that is burned the higher the risk of complications due to an increase in capillary permeability (swelling, hypovolemic shock etc.). In addition, the location of the burn is a major issue with the patient in option B. The burns are on the head and neck and front and back of the torso. Therefore, with head and neck burns always think about respiratory issues because the airway can become compromised due to swelling or an inhalation injury. And with torso burns that are on the front and back, the patient is at risk for circumferential burns that can lead to further respiratory compromise. The other options have burns that are isolated.

The nurse is caring for a client who has 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 RAT: The statement about not knowing what to do when people stare indicates that the client is not coping effectively. The nurse needs to assist the client in exploring coping techniques. Community reintegration programs can assist the psychosocial and physical recovery of the client with serious burns. 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 does not stare at the scars as much all indicate that the client is coping effectively.

A patient who is being treated for partial thickness burns on 60% of the body is now in the acute phase of burn management. The nurse assesses the patient for a possible Curling's Ulcer. What signs and symptoms can present with this condition? a. Swelling and pain on the area distal to the burn b. Burning, gnawing sensation pain in the stomach and vomiting c. Dark red or gray sores on the soles of the feet d. Difficulty swallowing and gagging

b RAT: This is a type of ulcer that occurs in the stomach, duodenum, due to a high amount of stress on the body from a burn. The blood supply to the factors that help protect the stomach lining from gastric erosion decreases and this allows for ulcers to form.

You're providing education to a group of local firefighters about carbon monoxide poisoning. Which statement is correct about the pathophysiology regarding this condition? a. "Patients are most likely to present with cyanosis around the lips and face." b. "In this condition, carbon monoxide binds to the hemoglobin of the red blood cell leading to a decrease in the ability of the hemoglobin to carry oxygen to the body." c. "Carbon monoxide poisoning leads to a hyperoxygenated state, which causes hypercapnia." d. "Carbon monoxide binds to the hemoglobin of the red blood cell and prevents the transport of carbon dioxide out of the blood, which leads to poisoning."

b RAT: This is the only correct statement about carbon monoxide poisoning.

A patient is presenting with bright red lips, headache, and nausea. The physician suspects carbon monoxide poisoning. As the nurse, you know the patient needs: a. Oxygen nasal cannula 5-6 Liters b. 100% oxygen via non-rebreather mask c. Continuous Bipap d. Venturi mask 6 L oxygen

b RAT: This is the treatment for carbon monoxide poisoning.

A patient experienced a full-thickness burn 72 hours ago. The patient's vital signs are WNL and urinary output is 50 mL/hr. This is known as what phase of burn management? a. Resuscitation/Emergent b. Acute c. Rehabilitative

b RAT: This phase starts when capillary permeability has returned to normal and the patient's vitals are WNL and ends with wound closure. The phase after this is rehabilitative.

During the acute phase of burn management, what is the best diet for a patient who has experienced severe burns? a. High fiber, low calories, and low protein b. High calorie, high protein and carbohydrate c. High potassium, high carbohydrate, and low protein d. Low sodium, high protein, and restrict fluids to 1 liter per day

b RAT: This type of diet promotes wound healing and meets the caloric demands of the body.

An older adult female arrives at the ED at 1100 with severe burns received after spilling boiling water on herself. The injury occurred at 0900. When administering fluid, what time does the first 8-hour period end? a. 1800 b. 1700

b RAT: fluid rate during the first 8 hour period should be calculated based on the time the injury occurred

The nurse notes a patient has full-thickness circumferential burns on the right leg. The nurse would: Select all that apply a. Place cold compressions on the burn and elevate the right leg below the heart level b. Assess the distal pulses in the right extremity c. Elevate the right leg above the heart level d. Place gauze securely around the leg to prevent infection

b, c RAT: The patient has burns that completely surround the front and back of the right leg. This can lead to compartment syndrome where the edema from the burn compromises circulation to the distal extremity. The nurse should elevate the extremity ABOVE heart level to decrease swelling and assess distal pulses in the extremity to confirm circulation is present.

A client is brought to the ED with partial-thickness burns to his face, neck, arms, and chest after trying to put out a care fire. The nurse should implement with nursing actions for this client? Select all that apply 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, c, e RAT: The primary goal for burn injury is to maintain a patent airway, administer IV fluids to prevent hypovolemic shock, and preserve vital organ functioning. An IV line should also be obtained and fluid resuscitation started. The client is kept warm because the loss of skin integrity causes heat loss. The client is placed NPO because of the altered gastrointestinal function that occurs.

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 for comfort b. Performs frequent handwashing c. Places plants in the client's room d. Performs gloved dressing changes e. Uses disposable dishes

b, d, e RAT: Frequent 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 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.

The nurse is encouraging range-of-motion exercises for the client, who states, "This hurts terribly; I don't want to do this." Identify the appropriate nursing responses. (Select all that apply.) a. "You have to do the exercises to get well." b. "Range-of-motion helps promote mobility." c. "Just visualize a beach to get your mind off of the pain." d. "Let me check when you were last given pain medication." e. "What techniques for pain management have you used in the past that were helpful?" f. "The health care provider has ordered these exercises, and it is important that you do them as instructed."

b, d, e RAT: Range-of-motion exercises should be actively performed at least 3 times daily for best benefit. Pain, or alterations in comfort, can interfere with performance of range-of-motion activities. Be sure the client is properly medicated so that pain medication has time to become effective before performing range-of-motion exercises. Helping the client reflect on pain management techniques that have been successful in the past can be useful. Telling the patient to do the exercises to get well, just to visualize a beach, and that the health care provider ordered the exercises, reflect nontherapeutic responses.

A 68 year old male patient has partial thickness burns to the front and back of the right and left leg, front of right arm, and anterior trunk. Using the Rule of Nines, calculate the total body surface area (TBSA) percentage that is burned? a. 40.5% b. 49.5% c. 58.5% d. 67.5%

c RAT: front and back of right leg (18%) front and back of left leg (18%) front of right arm (4.5%) anterior trunk (18%) Which equals 58.5%.

Burns- PEDS Tyler, a 3-year-old boy, was burned over 30% of his body by pulling a pot of hot coffee off the counter onto himself. His upper torso, right arm, and hand are burned. He is admitted to the burn unit emergency center. It is determined that the injury includes both full- and partial-thickness burns. How would this burn be classified? a. Mild b. Moderate c. Major d. Severe

c RAT: • Mild involve only partial-thickness burns over 10% of the total body surface area. • Moderate involve only partial-thickness burns, involving 10% to 20% of the total body surface area. • Major burns include partial-thickness burns involving greater than 20% of the total body surface area and full-thickness burns. • Severe is not a term used by the severity grading system adopted by the American Burn Association.

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. Impaired self-image d. Potential for infection

c RAT: A priority problem of impaired self-image is expected during the rehabilitation phase. During this phase, the client is discharged and his or her life is not the same. A priority problem of impaired 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.

The nurse is caring for a client who has burns. Which question does the nurse ask the client and family to best 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?" d. "Would you like to see a counselor?"

c RAT: Asking how the client and family have handled similar situations in the past best 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 RAT: Asking the client to tell the nurse more best 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.

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 (12.9 mmol/L) b. Creatinine, 2.8 mg/dL (248 mcmol/L) c. Urine output, 40 mL/hr d. Urine specific gravity, 1.042

c RAT: Clinical improvement based on fluid resuscitation for a burn client correlates with a urine output of between 30 and 50 mL/hr or 0.5 mL/kg/hr. A BUN of 36 mg/dL (12.9 mmol/L) is above normal, a creatinine of 2.8 mg/dL (248 mcmol/L) is above normal, and a urine specific gravity of 1.042 is above normal.

A patient has experienced full-thickness burns to the face and neck. As the nurse it is priority to: a. Prevent hypothermia b. Assess the blood pressure c. Assess the airway d. Prevent infection

c RAT: Due to the location of the burns (face and neck), the patient is at major risk for respiratory issues due to damage to the upper airways and the risk of an inhalation injury.

A client with burn injuries is 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 RAT: During the first 24 hours after a burn injury, the nurse's first priority is to administer 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 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 RAT: Indicators of wound healing include the presence of granulation, reepithelialization, and scar tissue formation. Pale, boggy, dry, or crusted granulation tissue is indicative of infection, as are increasing wound drainage and sloughing of grafts.

After receiving report on a patient receiving treatment for severe burns, you perform your head-to-toe assessment. On arrival to the patient's room you note the room temperature to be 75° F. You will: a. Decrease the temperature by 5-10 degrees to prevent hyperthermia. b. Leave the temperature setting. c. Increase the temperature to a minimum of 85° F.

c RAT: Patients with severe burns can NOT regulate their temperature and are at risk for hypothermia. The room temperature should be a minimum of 85° F.

Your patient with severe burns is due to have a dressing change. You will pre-medicate the patient prior to the dressing change. The patient has standing orders for all the medications below. Which medication is best for this patient? a. IM morphine b. PO morphine c. IV morphine d. Subq morphine

c RAT: The best route that is predictable and easily absorbed is via the IV route in burn victims.

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 RAT: The client with burn injury is at highest 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 (6.1 mmol/L). d. Urine output since admission is 370 mL.

c RAT: The greatest concern for the nurse is to notice an elevated serum potassium level that can cause cardiac dysrhythmias and arrest. 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.

A patient is in the acute phase of burn management. The patient experienced full-thickness burns to the perineum and sacral area of the body. In the patient's plan of care, which nursing diagnosis is priority at this time? a. Impaired skin integrity b. Risk for fluid volume overload c. Risk for infection d. Ineffective coping

c RAT: The patient is now in the acute phase where fluid resuscitation was successful and ends with wound closure. Therefore, during this stage diuresis occurs (so fluid volume deficient could occur NOT overload) and INFECTION. The location of the burns increases the risk of infection because these areas naturally harbor bacteria. Therefore, this takes priority because during this phase wound healing is promoted.

Based on the depth of the burn in the attached photo, you would expect to find: a. report of sensation to only pressure b. blanching c. anesthetization to feeling d. extreme pain

c RAT: This is a 3rd degree to 4th degree burn (full-thickness) and the nerves that detect pain are destroyed. The patient would have no feeling or experiences an extreme decrease sensation to pain.

The _____________ layer of the skin helps regulate our body temperature. a. Epidermis b. Dermis c. Hypodermis d. Fascia

c RAT: This layer contains fatty tissue, veins, arteries, nerves and helps insulate the muscles, bones, organs and helps REGULATE our body temperature.

Burns- PEDS What is the analgesic of choice for Tyler's pain? a. Acetaminophen b. Codeine c. Meperidine (Demerol) d. Morphine

d RAT: • Acetaminophen is used in combination with an opioid such as codeine only in children with less severe injuries. • Codeine is used in combination with a nonopioid such as acetaminophen only in children with less severe injuries. • Meperidine is not recommended for chronic use (or for more than 48 hr at a time) because of the accumulation of its metabolite, normeperidine. Normeperidine is a central nervous system stimulant that can produce anxiety, tremors, myoclonus, and generalized seizures. • Morphine sulfate is the drug of choice because of its extensive distribution.

Which assessment finding does the nurse interpret as demonstrating a client's fluid resuscitation adequacy? a. Decreased skin turgor b. Decreased pulse pressure c. Decreased core body temperature d. Decreased urine specific gravity

d RAT: A decrease in urine-specific gravity indicates that fluid replacement is improving. The higher the urine specific gravity, the higher the indication is of dehydration and inadequacy of fluid resuscitation. Increased—not decreased— skin turgor, pulse pressure, and core body temperature would be associated with fluid resuscitation adequacy.

Silver sulfadiazine is prescribed for the client with a burn injury. What laboratory finding requires the need for follow-up by the nurse? a. Glucose 99 b. Platelets 300,000 c. Magnesium 1.5 d. WBC 3,000

d RAT: Adverse effects for this medication include rash, itching, blue-green or gray skin discoloration, leukopenia, and interstitial nephritis. The nurse should monitor a CBC, particularly WBC. If leukopenia develops, the PHP is notified and the medication is typically discontinued. The WBS count in option d. is low and indicates leukopenia. The other lab values are not specific to this medication and are also WNL.

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 (ICU)? 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 RAT: An RN float nurse from ICU 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.

The client asks about ways to prevent carbon monoxide poisoning. Which teaching will the nurse provide? a. "You can see black smoke when carbon monoxide is in the air." b. "If you are experiencing carbon monoxide poisoning, your skin will begin turning blue." c. "The only way to get poisoned from carbon monoxide gas is if you are in the presence of a fire." d. "It is important to have carbon monoxide detectors in your home, because this is an odorless gas."

d RAT: Carbon monoxide is a colorless, odorless gas; it can be present in environments other than those associated with a fire. Exposure turns skin cherry red. Having carbon monoxide detectors in the home can decrease the likelihood of exposure to this gas, if it is generated as the result of a fire, or as a result of a gas leak from appliances.

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 maintain a desirable weight d. Planning additions to the standard nutritional pattern

d RAT: Consultation with the dietitian is required to help the client achieve the correct nutritional balance. 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. 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.

Silver sulfadiazine is prescribed for the client with a partial-thickness burn, and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments? a. "The medication is an antibacterial." b. "The medication will help heal the burn." c. "The medication should be applied directly to the wound." d. "The medication is likely to cause stinging every time it is applied."

d RAT: Silver sulfadiazine is an antibacterial that has a broad spectrum of activity against gram +/-bacteria and yeast. It is applied directly to the wound to assist in healing. It does not cause stinging when applied.

The nurse is assessing a burn client who is at risk for developing acute respiratory distress syndrome (ARDS). The nurse should assess for which earliest sign of ARDS? a. Bilateral wheezing b. Inspiratory crackles c. Intercostal retractions d. Increased respiratory rate

d RAT: The earliest detectable signs of ARDS is an increased RR. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles.

A burn victim is exhibiting increased 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 RAT: The nurse first needs to adjust and titrate the intravenous fluid rate on the basis of urine output plus serum electrolyte values. 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.

A patient is receiving IV Lactated Ringers 950 mL/hr post 18 hours after a receiving a severe burn. The patient urinary output is 20 mL/hr. As the nurse your next nursing action is to: a. Increase the IV fluids b. Continue to monitor the patient c. Decrease the IV fluids d. Notify the physician of this finding

d RAT: The patient's urinary output is too low and needs more fluids. It should be at least 30 mL/hr. Therefore, the nurse must notify the physician for further orders. The nurse can NOT increase or decrease IV fluids without a physician's order.

During the emergent phase of burn management, you would expect the following lab values: a. Low sodium, low potassium, high glucose, low hematocrit b. High sodium, low potassium, low glucose, high hematocrit c. High sodium, high potassium, high glucose, low hematocrit d. Low sodium, high potassium, high glucose, high hematocrit

d RAT: Think about the increase in the capillary permeability that happens with severe burns, which causes the plasma to leave the intravascular system and enter the interstitial tissue: * Low sodium d/t it leaving with the plasma to the interstitial tissue and drops the levels in the blood * High potassium d/t damaged cells lysis and leak potassium which increases the leave in the blood * High glucose d/t stress response leads the liver to release glycogen and this increases levels * High hematocrit d/t when the plasma leaves the intravascular system (the fluid) it causes the blood to become more concentrated so hematocrit increases (this will decrease when the patient's fluid is replaced).