Honan Nursing Management: Patients With Burn Injury

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."

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

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

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

Applying knee splints

Which of the following skin substitutes is a nylon-silicone membrane coated with a protein?

Biobrane

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

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 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 with a burn injury is in acute stress. Which of the following complications is prone to develop in this client?

Gastric ulcers

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

Hemodilution

A child tips a pot of boiling water onto his bare legs. The mother should:

Immerse the child's legs in cool water.

The nurse's hourly assessment of a male patient with burns reveals that the patient's blood pressure is trending downward and that his heart rate is trending upward. What intervention has the potential to resolve these trends?

Increasing the rate of the patient's fluid resuscitation

The nurse is administering an analgesic to a patient with major burns. What is the recommended route for administration for this patient?

Intravenous

A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene?

Irrigate the wounds with water.

Which of the following is the effect of protein catabolism in a client with severe burns?

It compromises wound healing and immunocompetence.

A patient has just been admitted after experiencing severe burns in an automobile accident. What intravenous solution should the nurse anticipate administering during this patient's immediate care?

Lactated Ringer's

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

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

Pulmonary system

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

When the area of burn is irregular in shape and is scattered over multiple areas of the body, which is the best method for the nurse to obtain a quick assessment of the total body surface area of the burn?

Use client's palm size

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

A client has been burned significantly in a workplace accident. Which conditions create the need for immediate intensive care by specifically trained personnel? Select all that apply.

hypotension fluid loss fluid shift

A nurse is reading a journal article about the morbidity and mortality associated with burn injury. The nurse demonstrates understanding of the article by identifying which population as having the highest mortality and morbidity rates?

older adults

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.

Which antimicrobials is not commonly used to treat burns?

tetracycline

The nurse participates in a health fair about fire safety. When clothes catch fire, which intervention helps to minimize the risk of further injury to an affected person at a scene of a fire?

Roll the client in a blanket.

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.

A client presents to the emergency department following a burn injury. The client has burns to the abdomen and front of the left leg. Using the rule of nines, the nurse documents the total body surface area percentage as

18%.

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

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%

The nurse observes for fluid and electrolyte changes during the acute phase based on the knowledge that fluid remobilization usually begins:

After 48 to 72 hours later, when fluid is moving from the interstitial to the intravascular compartment.

The nurse is caring for a patient who sustained a deep partial-thickness burn injury 36 hours ago. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to which of the following nursing diagnoses?

Acute pain

A client is brought to the emergency department after being involved in a house fire. The client has superficial burns on the arms and legs but emergency medical personnel report that the client may have smoke inhalation. The client is complaining of a headache and some dizziness. The nurse obtains the client's carboxyhemoglobin level which is 15%. Which action by the nurse would be most appropriate?

Administer 100% oxygen.

A teenage boy has been brought by ambulance to the emergency department from a house fire in which he has suffered extensive injuries. In addition to burns, early blood tests reveal carbon monoxide poisoning. This assessment finding will be treated by what intervention?

Administration of 100% oxygen

Which of the following terms refers to a graft derived from one part of a patient's body and used on another part of that same patient's body?

Autograft

Which term refers to a graft derived from one part of a client's body and used on another part of that same client's body?

Autograft

Following a serious thermal burn, which complication will the nurse take action to prevent first?

Hypovolemia

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

Hoarseness of the voice

A patient in the emergent/resuscitative phase of a burn injury has had her lab work drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what?

Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis

Which of the following is to be expected soon after a major burn? Select all that apply.

Hypotension Tachycardia Anxiety

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 mL/kg/hour.

A nurse is providing care to a client who has sustained a major burn injury. When developing the client's plan of care, the nurse anticipates that the greatest amount of fluid shifting would occur at which time?

about 24 hours after the burn

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. What depth of burn injury does the client have?

full thickness (third degree)