Chapter 66: Caring for Clients with Burns Prep U

Several temporary and permanent sources are available for covering a burn wound. These may be manufactured synthetically, obtained from a biologic source, or a combination of the two. Which graft is described as a biologic source of skin similar to that of the client?

allograft

The nurse recognizes the first dressing change at the site of an autograft is performed

as soon as foul odor or purulent drainage is noted, or 2 to 5 days after surgery.

When caring for a client with burns, a nurse should change the wound dressing at least once every:

day.

A client with deep partial-thickness and full-thickness burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse provides additional client teaching because these exercises may:

dislodge the autografts.

To meet early nutritional demands for protein, a 198-lb (90-kg) burned patient will need to ingest a minimum of how much protein every 24 hours?

180 g/day

In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client?

A urine output consistently above 40 ml/hour

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

Dry and pale white.

The nurse caring for a client who is recovering from full-thickness burns is aware of the client's risk for contracture and hypertrophic scarring. How can the nurse best reduce this risk?

Encourage physical activity and range-of-motion exercises.

The nurse is caring for a client with burns over 55% of total body surface area. Which information is essential for the nurse to document to guide the care of this client? Select all that apply.

Pre-burn body weight Current list of medications Last tetanus immunization Current body temperature

A nurse formulates a nursing diagnosis of Impaired physical mobility for a client with full-thickness burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase?

Related to circumferential eschar

A manufacturing plant has exploded, and the nurse is assigned to triage burn victims as they arrive to the hospital. Which is the most important question for the nurse to ask prior to the arrival of victims?

"Are the burns associated with chemicals used in the plant?"

A burn client is transitioning from the acute phase of the injury to the rehabilitation phase. The client tells the nurse, "I can't wait to have surgery to reconstruct my face so I look like I used to." What would be the nurse's best response?

"That's something that you and your doctor will likely talk about after your scars mature."

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

Mafenide (Sulfamylon)

A client arrives in the emergency department after being burned in a house fire. The client's burns cover the face and the left forearm. What extent of burns does the client most likely have, measured as a percentage?

18

A client 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 client's needs?

A patient-controlled analgesia (PCA) system

The nurse in the emergency department receives a patient who sustained a severe burn injury. What is the priority action by the nurse in this situation?

Establish a patent airway.

A client is brought to the emergency department from the site of a chemical fire, where the client 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 client's arm?

Full thickness

Which type of burn injury requires skin grafting?

Full-thickness

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

Hoarseness of the voice

The nurse is caring for a patient who sustained a full-thickness burn to his arm when he was scalded with boiling water. How did the nurse determine that the patient's burns are full-thickness burns?

Identification by the destruction of the dermis and epidermis

The nurse knows that inflammatory response following a burn is proportional to the extent of injury. Which factor presents the greatest impact on the ability to modify the magnitude and duration of the inflammatory response in a client with a burn?

Preexisting conditions

A nurse is required to monitor the effectiveness of fluid resuscitation in a client who is being treated for burns. Which of the following assessments would indicate the success of the fluid resuscitation?

The client's urinary output is 0.5 to 1 mL/kg/hour.

The open method (exposure method) of burn care, which exposes the burned areas to air, has been virtually abandoned since the advent of effective topical antimicrobials. It is still used on a small scale however. On which areas of the body are burns still being treated this way? Select all that apply.

The face The perineum

As the first priority of care, a patient with a burn injury will initially need:

a patent airway established.

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

Replace lost fluids and electrolytes.

The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to

decrease catabolism.

Within the burn unit, clients may develop complications based on the type of burn they endured. Which burns have a common complication of cardiac dysrhythmias?

electrical

Specific potential complications are common to specific types of burns. Which burns can impair ventilation?

face, neck, chest

A client with a superficial partial-thickness solar burn (sunburn) of the chest, back, face, and arms is seen in urgent care. The nurse's primary concern should be:

pain management.

A nurse who provides care on a burn unit is preparing to apply a client's ordered topical antibiotic ointment. What action should the nurse perform when administering this medication?

Apply a layer of ointment approximately 1/16 inch thick.

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

premedicating the client with an analgesic prior to application.

What laboratory value observed by the nurse is unexpected during the fluid remobilization phase of a major burn?

Serum sodium level of 140 mEq/L

A client is scheduled for an allograft to a burn wound, and the client asks for an explanation. What information will the nurse include in the client teaching?

"An allograft is a temporary wound covering obtained from cadaver skin."

A sample consensus formula for fluid replacement recommends that a balanced salt solution be administered in the first 24 hours of a chemical burn in the range of 2 mL/kg/% of burn, with 50% of the total given in the first 8 hours postburn. A 176-lb (80-kg) man with a 30% burn should receive a minimum of how much fluid replacement in the first 8 hours?

2,400 mL

How many people die of burn injuries each year in the United States?

3300

A nurse is caring for a client who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis?

Acute pain

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

BUN: 28 mg/dL

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

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

A nurse is teaching a client with a partial-thickness wound how to wear the elastic pressure garment. How often should the nurse instruct the client to wear this garment?

Continuously

A client with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the client closely for what signs of the onset of burn shock?

Decreased blood pressure

The spouse of a client who was struck by lightning asks the nurse why the areas involved seems so small but the damage is extensive. Which is the best explanation from the nurse?

Electrical burns usually follow an internal path.

A client 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 nurse's immediate, priority concern when planning this client's care?

Fluid status

A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following?

Full-thickness

A person suffers leg burns from spilled charcoal lighter fluid. A family member extinguishes the flames. While waiting for an ambulance, what should the burned person do?

Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel.

A triage nurse in the emergency department (ED) receives a phone call from a frantic parent who saw their 4-year-old child tip a pot of boiling water onto themselves. The parent has called an ambulance. What should the nurse in the ED receiving the call instruct the parent to do?

Immerse the child in a cool bath.

A client's burns have required a homograft. During the nurse's most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurse's most appropriate response?

Inform the primary care provider promptly because the graft may need to be removed.

A client is admitted to the burn unit after being transported a long distance. The client has burns to the groin area and circumferential burns to both upper thighs. When assessing the client's legs distal to the wound site, the nurse should be cognizant of the risk of what complication?

Ischemia

Which type of debridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar?

Mechanical

A public health nurse is educating a group of administrators about decreasing hospitalizations for burns. Which population will the nurse note as the target population for burn injuries?

Older adults

The nurse is caring for a patient who sustained a major burn. What serious gastrointestinal disturbance should the nurse monitor for that frequently occurs with a major burn?

Paralytic ileus

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

Pulmonary system

The nurse is caring for a client 48 hours after their burn injury. Which treatment will the nurse anticipate to reduce the client's risk of mortality?

Remove burned tissue

Leukopenia within 48 hours is a side effect associated with which topical antibacterial agent?

Sulfadiazine, silver (Silvadene)

The nurse is providing wound care for a client with burns to the lower extremities. Which topical antibacterial agent carries a side effect of leukopenia that the nurse should monitor for within 48 hours after application?

Sulfadiazine, silver (Silvadene)

Which of the following is a potential cause of a superficial partial-thickness burn?

Sunburn

A patient has a burn injury that has damaged the epidermis. There are no blisters, and the skin is pink in color. This type of burn injury would be documented as which of the following?

Superficial

A client has a skin graft and is also using a pressure garment as part of the recovery following a burn injury. Which of the following measures would the nurse advise the client to follow?

Use a sunscreen with a high SPF while outdoors to protect against pigment changes.

The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories. The nurse recognizes this intervention is to promote

decreased catabolism.

A client has received significant electrical burns in a workplace accident. What occurrence makes it difficult to assess internal burn damage in electrical burns?

deep tissue cooling

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

inflammatory

Which antimicrobials is not commonly used to treat burns?

tetracycline

The nurse cares for a client with superficial partial-thickness burn injuries to the lower extremities. The client is ordered IV morphine for pain. The nurse understands narcotics are given via IV during the initial management of pain because

tissue edema may interfere with drug absorption via other routes.

The nurse cares for a client with extensive burn injuries. Which parameter(s) would the nurse evaluate to determine if the client is receiving adequate fluid resuscitation? Select all that apply.

Heart rate Urine output

The nurse recognizes that which of the following provide clues about fluid volume status? Select all that apply.

Hourly urine output Daily weights Skin turgor

The nurse is caring for a client who has sustained severe burns to 50% of the body. The nurse is aware that fluid shifts during the first week of the acute phase of a burn injury cause massive cell destruction. What should the nurse report if it occurs immediately after burn injury?

Hyperkalemia

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?

Wrap cool towels around the affected extremity intermittently.

A client has a third-degree burn on the leg. The wound is being treated by the open method. After about 4 days, a hard crust has formed around the leg and is impairing the circulation to the leg. What procedure would be done to relieve pressure on the affected area?

escharotomy

A client has a burn on the leg related to an engine fire. When the burn area was assessed, it was determined that the client felt no pain in the area and that it appeared leathery. How would the nurse document the depth of burn injury this client has?

full thickness (third degree)

Initial first aid rendered at the scene of a fire includes preventing further injury through heat exposure. Which intervention could contribute to tissue hypoxia and necrosis and therefore should be avoided?

Application of ice

A nurse practitioner administers first aid to a patient with a deep partial-thickness burn on his left foot. The nurse describes the skin involvement as the:

Epidermis and a portion of deeper dermis.

Which intervention helps to minimize the risk of further injury to an affected person at the scene of a fire?

Roll the client in a blanket

At the scene of a fire, the first priority is to prevent further injury. What are interventions at the site that can help to prevent injury? Select all that apply.

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

Which zone of burn injury sustains the most damage?

Inner

Which type of burn injury involves destruction of the epidermis and upper layers of the dermis as well as injury to the deeper portions of the dermis?

Deep partial-thickness

A client recovering from burn injuries over both forearms reports itching of the wounds. Which action will the nurse take to enhance the client's comfort?

Instruct to pat and not scratch the areas.

A client's burns are estimated at 36% of total body surface area; fluid resuscitation has been ordered in the emergency department. After establishing intravenous access, the nurse should anticipate the administration of what fluid?

Lactated Ringer

When providing initial assessment to a client who has suffered an electrical burn, which assessment finding will provide the most important data?

Location of entry and exit wounds

A patient has been prescribed Acticoat as a burn wound treatment. Which of the following is accurate regarding application of Acticoat?

Moisten with sterile water only.

The nurse is preparing to provide wound care to a client with extensive burns. Which characteristic of the dressing will the nurse use to select the type of topical therapy? Select all that apply.

Penetrates eschar without toxicity Effectiveness against organisms Cost-effective and acceptable to the client Easy to apply and remove to minimize pain

A home care nurse is performing a visit to a client's home to perform wound care following the client's hospital treatment for severe burns. While interacting with the client, the nurse should assess for evidence of what complication?

Posttraumatic stress disorder

A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body?

27%

A sample consensus formula for fluid replacement recommends that an isotonic solution be administered in the first 24 hours of a burn in the range of 2 to 4 mL/kg/% of burn with 50% of the total given in the first 8 hours postburn. A 176 lb (80 kg) man with a 30% burn should receive a minimum of how much fluid replacement in the first 8 hours?

2,400 mL

A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned?

36%

The nurse provides care for a client with a full-thickness, circumferential burn of the left lower leg. During the nurse's initial shift assessment, the client is resting and the physical assessment of the left lower extremity is unremarkable. One hour later, the nurse notes the pulses of the left lower leg cannot be obtained by a Doppler ultrasound device, and the capillary refill of the left great toe is greater than 2 seconds. What is the nurse's best response based on the clinical findings?

Contact the primary care provider and prepare for an escharotomy.

A nurse is caring for a client 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?

Prevention of venous thromboembolism

A client is in the acute phase of a burn injury. One of the nursing diagnoses in the plan of care is Ineffective Coping Related to Trauma of Burn Injury. What interventions appropriately address this diagnosis? Select all that apply.

Promote truthful communication. Teach the client coping strategies. Provide positive reinforcement.

A client who was burned in a workplace accident has completed the acute phase of treatment and the plan of care has been altered to prioritize rehabilitation. What nursing action should be prioritized during this phase of treatment?

Providing education to the client and family

A client experienced a 33% TBSA burn 72 hours ago. The nurse observes that the client's hourly urine output has been steadily increasing over the past 24 hours. How should the nurse best respond to this finding?

Recognize that the client is experiencing an expected onset of diuresis.

An emergency department nurse learns from the paramedics that the team is transporting a client who has suffered injury from a scald from a hot kettle. What variables will the nurse consider when determining the depth of burn?

The causative agent

An emergency department nurse has just admitted a client with a burn. What characteristic of the burn will primarily determine whether the client experiences a systemic response to this injury?

The total body surface area (TBSA) affected by the burn

A nurse is developing a care plan for a client 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?

To prevent contractures

An emergency department nurse has just received a client with burn injuries brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the client's body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period?

Administer IV fluids.

When being discharged from the burn unit after having skin grafting done, what instructions should the client receive about the use of a pressure garment? Select all that apply.

All are correct.

A client has experienced burns to the upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action?

Assess the client's peripheral pulses distal to the dressing.