Critical Care Exam 3: Burns Specifics

When using the Palmer method to estimate the extent of the burn injury, the nurse determines the palm is equal to which percentage of total body surface area?

1%

Which of the following is to be expected soon after a major burn? Select all that apply. A. Hypotension B. Tachycardia C. Anxiety D. Hypertension E. Bradycardia

A. Hypotension B. Tachycardia C. Anxiety

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.

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 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 2 mL of LR x 80 kg x 30 = 4,800 mL 4,800 ÷ 2 (give half in the first 8 hours) = 2,400 mL

Describe the three zones of injury for burns.

Each burned area has three zones of injury. Zone of Coagulation: -The inner area, where cellular death occurs. -Sustains the most damage. Zone of Stasis: -The middle area. -Causes compromised blood supply, inflammation, and tissue injury. Zone of Hyperemia: -Outer area. -Sustains the least damage.

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.

A client is brought to the ED with burns exceeding 20% of total body surface area. Which is the primary nursing intervention in the care of this client? Why?

Fluid resuscitation with crystalloid and colloid solutions. -Restores the intravascular volume and prevents hypovolemic shock and renal failure.

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 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.

Which is the primary reason for placing a client in a horizontal position while smothering flames are present?

To keep fire and smoke from airway.

A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem?

Urine output < 30 mL/hr

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?" Rationale: If the victim has sustained chemical burns, the chemicals must be removed from the skin to prevent burns to others, including the triage nurse and emergency staff.

The nurse has completed teaching home care instructions to a client being discharged from the burn unit. Which statement from the client indicates the need for further teaching?

"As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help."

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

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

27% Anterior trunk = 18% Whole arm = 9% 18 + 9 = 27%

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

27% Back = 18% Whole arm = 9% 18 + 9 = 27

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% Left whole arm = 9% Left anterior leg = 9% Anterior trunk = 18% 9 + 9 + 18 = 36

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

A patent airway established.

Which of the following measures can be used to cool a burn?

Application of cool water.

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

Applying knee splints.

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.

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

Decrease catabolism (destructive form of metabolism)

Which type of burn injury requires skin grafting?

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.

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

Hyperkalemia.

The nurse recognize what as an early sign of sepsis in a client with a burn injury? (3)

In clients with burn injuries early sepsis can be hard to detect. Clients with burn injuries exhibit tachycardia, tachypnea, and elevated body temperature, all typical indications of sepsis. In the client with burn injury, indications of sepsis include: 1. Elevated serum glucose values. 2. Increased heart rate. 3. Narrowing mean arterial pressure.

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which IV fluid does the nurse plan to administer first?

Lactated Ringer's solution

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

Liquid blood component is lost into extravascular space.

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

Mechanical

The nurse determines which statement reflects current research regarding the utilization of non-pharmacological measures in the management of burn pain?

Music therapy may provide reality orientation, distraction, and sensory stimulation.

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.

A client brought to the emergency department has been exposed to smoke and flames from a house fire. What assessment finding is most important to the nurse in determining care of the client?

Presence of soot around nasal passages.

A patient has been prescribed mafenide acetate cream for burn treatment. The nurse should educate the patient regarding which of the following?

Severe burning pain for up to 20 minutes.

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

Skin grafting will be necessary.

Determining the depth of a burn is difficult initially because there are combinations of injury zones in the same location. The area of intermediate burn injury is the zone in which blood vessels are damaged, but tissue has the potential to survive. This is called the zone of:

Stasis.

An explosion of a fuel tanker has resulted in melting of clothing on the driver and extensive full-body burns. The client is brought into the emergency department alert, denying pain, and joking with the staff. Which is the best interpretation of this behavior?

The client has experienced extensive full-thickness burns. Rationale: In full-thickness burns, nerves are damaged and consequently painless.

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.

A client receiving emergency treatment for severe burns has just been assessed to establish the burn depth. Why is a nurse asked to reassess the burn depth after 72 hours?

The early appearance of the burn injury may change.

Which zone of burn injury sustains the most damage?

Zone of Coagulation (inner)