Module 11

A client with extensive burns has a new donor site. Which of the following considerations is important in positioning the client? A. Make the site dependent B. Avoid pressure on the site C. Keep the site fully covered D. Allow ventilation of the site

B a universal concern in the care of donor sites for burn care is to keep the site away from sources of pressure. Ventilation of the site and keeping the site fully covered are practices in some institutions but are not hallmarks of donor site care

8 yo child arrives at the emergency department with chemical burns to both legs which of the following treatments has priority for this child? A. Dilute the burns B. Apply sterile dressings C. Apply topical antibiotics D. Debride and graft the burns

A : the chemical needs to be removed by dilution. This will stop the burning process, then the others.

A client had been admitted to the burn unit with extensive full-thickness burns. Which of the following considerations has priority?A. Fluid status B. Body image C. Level of pain D. Risk for infection

A in early burn care, the clients greatest need is fluid resuscitation because of the large volume fluid loss through the damaged skin. Infection, body image, and pain are important concerns, but do not have precedence over fluids in early care.

A 42yr sustains a moderate burn injury. They have received a Td 3 years ago. An appropriate intervention would be to administer which of the following immunizations? A. 0.5 ml of tetanus toxoid I.M B. 0.5 ml of tetanus toxoid I.V. C. 250 U of Hyper-Tet I.M. D. 250 U of Hyper-Tet I.V

A tetanus prophylaxis is given to all clients with moderate to severe burn injuries If its longer than 5 yrs since last or if no hx. The correct dosage is 0.5ml IM one time if has been vaccinated prior, if more than 10 years will receive hyper-tet one-time 250 U. There is no IV for of tetanus

List 3 initial priorities in the emergent phase

Airway Fluid Resuscitation Pain control

A client weighing 132 pounds (60 kilograms) with burns over 35% of the body arrives at the hospital an hour after being rescued from a fire. Which amount of lactated Ringer solution would the nurse anticipate being infused in the next 8 hours? A. 2100 ml B. 4200 mL C. 6300 mL D. 8400 mL

B In the first 8 hours, 4200 mL should be infused. According to the Parkland (Baxter) formula, one-half of the total daily amount of fluid should be administered in the first 8 hours. Because the client weighs 60 kg (132 pounds + 2.2 kg = 60 kg), the calculation is 60 kg x 4 mL/kg x 35% burns = 8400 mL per day; half of this amount should be infused within the first 8 hours. 2100 mL, 6300 mL, and 8400 mL are incorrect calculations.

The nurse is caring for a client during the emergent phase of a severe burn injury. Which parenteral intervention prescribed by the health care provider would the nurse question? A. Colloids B. Potassium C. Hypertonic saline D. Lactated Ringer solution

B Potassium replacement generally is not indicated in the initial management of burns because hyperkalemia results from the liberation of potassium ions from the injured cells. Colloids are given to draw fluid from edematous tissue back into the bloodstream. Hypertonic saline and lactated Ringer solution are given to replace fluid and electrolytes.

Adequate nutrition is essential for a burn client. Which of the following statements is correct about the nutritional needs of a burn client? A. The client needs 100 cal/kg throughout the hospitalization. B. The hypermetabolic state after a burn injury leads to poor healing. C. Controlling the temperature og the environment decreases caloric demands. D. Maintaining a hypermetabolic rate decreases the client's risk for infection.

B burns cause a hypermetabolic state resulting in protein and lipid catabolism that affects would healing. Calories need to be 1 ½ to 2 times the basal metabolic rates with at least 1.5 to 2 g/kg of body weight of protein daily. This high rate increases the risk for infection, and temperature control also takes away from energy used for tissue repair, so keep from being too cold or hot.

A 3YR old child is rated in the clinic for a burn to the left leg. Which of the following ways to measure burn size would be accurate for this child? A. The rule of nines B. Percentage based on the child's weight C. The child's palm equals 1% of the child's BSA D. Percentage can't be determined without knowing the type of burn

C palm of a child is equal to 1% of that child's body surface. The rule of nines is used for children ages 14 and older. Burn type has no determination of %. The weight is important to calculate fluid replacement but not estimate % or can use Lund and Browder.

Using the Rule of Nines, determine % of burn: anterior torso, face, & bil. anterior arms

Face: 4.5 Ant. torso: 18 Ant. arms: 9 = 31.5%

What effect does carbon monoxide have on RBCs?

It displaces O2 from Hgb (higher affinity to bind)

List 4 classifications of burns

Superficial Superficial to deep partial-thickness Full thickness Deep full thickness

Using the Parkland Formula: a person weighing 75 kg with burns to 20% of his or her BSA would require how much fluids and when? • Ml/hr

• 4ml x 75kg x 20% = 6,000 mL of fluid replacement within 24 hours. • The first half of this amount is delivered within 8 hours from the burn incident, (3L) =375ml/hr• and the remaining (3L) fluid is delivered in the next 16 hours. =187.5ml/hr If it has been an hour since the incident, then fluid calculation would be in the first 7 hours.

A child weighing 10kg has a deep partial- thickness burn to 40% of his body surface area. The nurse will titrate this child's I.V. fluids to achieve which of the following hourly urinary outputs? A. 5ml B. 10ml C. 30ml D. 50ml

B for children the urinary output should be 1-2ml/kg an hour for adequate kidney perfusion and fluid resuscitation, adult should have 30-50ml/hr of output

The patient asks the nurse about the temporary graft they are receiving for their burn injury. Which type of graft is used as a temporary covering once eschar is removed to help close and protect the wound? A. Integra B. Autograft C. Xenograft D. Cultured epithelial autograft

C Integra is an artificial skin and a permanent graft that provides a functional dermis and better chance of wound closure. Autograft is the ideal coverage for all patients with burns and has the highest chance of wound closure. Xenograft is used as a temporary covering once eschar is removed to help close and protect the wound. This graft is used for patients with 70% burns or burns that do not have unburned skin to use as donor for autografting.

Which type of burns would the nurse assessing burn injuries identify on fire survivors with pink to cherry-red skin with blisters? A. First-degree burns B. Third-degree burns C. Fourth-degree burns D. Second-degree burns

D Blister formation and pink to cherry-red skin indicate partial-thickness burns that are second-degree burns. In first-degree burns, the client experiences moderate to severe tenderness and redness of the skin, Third- degree and fourth-degree burns involve dry and leathery skin with impaired sensation when touched.

An adolescent is admitted to the burn unit with partial-thickness burns of both arms and the chest. Which information about burns would guide the nurse's plan of care? A. Burns are extremely painful and disfiguring. B. Some grafting of the burned area is necessary. C. Pressure dressings and prolonged hydrotherapy are required. D. Spontaneous epithelial regeneration occurs within several weeks.

D If there is no subsequent infection of the burned areas, wound healing should be uneventful. Although partial-thickness burns are painful, they usually heal with little or no scarring. Regeneration will occur unless there is further insult to the burn injury, such as infection; grafting should not be necessary. Occlusive dressings may be applied to minimize the discomfort of frequent dressing changes; hydrotherapy is not required for partial-thickness burns.

Which of the following characteristics is correct for a deep partial-thickness burn? A. Pain and redness B. Minimal damage to the epidermis C. Necrotic tissue through all layers of skin D. Necrotic tissue through most of the dermis

D a deep partial thickness burn causes necrosis through epidermal and dermal layers. With deep burns the nerve fibers are destroyed, and the client doesn't feel pain in affected area

Which of the following characteristics is seen with deep partial-thickness burn wounds? A. Blanching B. Erythema C. Eschard D. Fluid-filled vesicles

D the characteristics of deep partial thickness skin destruction (second degree burns) are fluid filled vesicles, Erythema and blanching on pressure are partial thickness, eschar is full thickness

Determine BSA% and Parkland formula for a client weighing 160 pounds, burned on their anterior torso and bilateral arms.

• 160 divided by 2.2= 73• Ant torso=18% + Bil. Ant arms= 9%; total= 27%• 4ml X27% X 73= 7,884ml in 24 hours• 3,942ml/8hrs or493ml/h• 3,942ml/16hrs= 246ml/hr

Using Parkland formula to calculate the fluid resuscitation for 24 hrs: 187lb & 31.5% BSA

187 / 2.2 = 85 85 x 31.5 x 4 = 10,710

A client arrives in the emergency department 20 minutes after sustaining a major burn injury to 40% of his body. After initiating an I.V. line, which of the following interventions would the nurse perform next for this client? A. Insert an indwelling catheter B. Apply Silvadene cream to the burn C. Shave the hair around the burn D. Obtain cultures from the deepest area burned

A : I.V fluid will be given to prevent hypovolemic shock. The fluids are titrated based on the urinary output. To monitor this to exact an indwellling cath is needed. Others are not as immediate.

A patient is admitted to the emergency room aftersustaining an electrical burn with contact pointsto his right hand and left foot. The patient is beingresuscitated with lactated Ringer's solution using theconsensus formula. A urinary catheter was placed,and the nurse observes myoglobin in the urine alongwith a decrease in urine output. What is the mostappropriate nursing action? A. Give the patient a normal saline fluid bolus. B. Notify the physician and anticipate increasingthe intravenous fluid rate. C. Administer a diuretic. D. Continue monitoring the patient.

B

Full-thickness circumferential burns to the chest cause difficulty breathing. Which of the following surgical interventions is needed to correct this condition? A. Intubation B. Eschartotomy C. Needle thoracentesis D. Insertion of a chest tube

B : Escharotomy is a surgical incision used to relieve pressure from edema. It's needed with circumferential burns and prevent chest expansion or circulatory compromise. Intubation is performed to maintain a patent airway. Insertion of a chest tube and needle thoracenteses are preformed to relieve a pneumothorax.

What are the first considerations for a patient that has an electrical burn? : A. Determining an entrance and exit wound B. Determine a cardiac rhythm C. Determine any other injuries D. Determine amount/color of urinary output

B ABCs- it is common to have the electrical current stop the heart, there will always be an exit wound, the kidneys will need to be assessed by urinary output and labs

A client has just arrived at the emergency department after sustaining a major burn injury. Which of the following metabolic alteration is expected during the first 8 hours post-burn? A. Hyponatremia and hypokalemia B. Hyponatremia and hyperkalemia C. Hypernatremia and hypokalemia D. Hypernatremia and hyperkalemia

B During the first 48 hours after a burn, capillary permeability increases, allowing fluids to shift from the plasma to the interstitial spaces. Ths fluid is high in sodium, causing a decrease in serum sodium levels. Potassium also leaks from the cells into the plasma, causing hyperkalemia.

Which interventions will be contraindicated for a client who has a fracture and compartment syndrome? Select all that apply. One, some, or all responses may be correct. A. Splitting the cast in half B. Applying cold compresses C. Reducing the traction weight D. Loosening the client's bandage E. Elevating the extremity above heart level

BE Cold compresses and elevating above the heart level are contraindicated for compartment syndrome. Compartment syndrome is a condition in which swelling and increased pressure within a limited space (a compartment) press on and compromise the function of blood vessels, nerves, and tendons that run through that compartment. Application of cold compresses could result in vasoconstriction and exacerbate compartment syndrome. Elevating the extremity above heart level could lower venous pressure and slow arterial perfusion. Splitting the cast in half decreases pressure and is beneficial in treating compartment syndrome. Reducing traction weight is beneficial because it decreases external circumferential pressure. Loosening the bandage is beneficial because it decreases pressure.

A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse calculates that he has sustained burns to which of the following percentages of his body? A. 9% B. 18% C. 27% D. 36%

C According to the rule of nines, the posterior trunk, anterior trunk and legs are 18% of the total body surface, and the perineum is 1%. In this case, the client received burns to his back (18%) and one arm (9%) = 27% of his body

Which clinical indicator would the nurse identify when a client has a fat embolus, but would not be present with a thromboembolus? A. Anxiety B. Restlessness C. Pinpoint red spots on the chest D. Decreased arterial oxygen level

C Fat emboli cause capillary fragility; rupture of capillary walls results in pinpoint red spots (petechiae) on the feeling of dread or impending doom. chest and conjunctiva of the eye. Anxiety occurs in both fat embolism and thromboembolism. There often is a Restlessness and confusion from cerebral hypoxia occur in both fat embolism and thromboembolism. The arterial oxygen may be decreased in both fat embolism and thromboembolism.

When advising parents about the prevention of burns from tap water, which of the following instructions should be given? A. Set the water-heater temperature at 130 degrees F or less. B. Run the hot water first, then adjust the temperature with cold water. C. Before you put your infant in the tub, first test the water with your hand. D. Supervise an infant in the bathroom, only leaving him for a few seconds, if needed.

C need to test water first for hot spots. Water heaters should be set at 120 degrees. Never leave an infant or child unattended. The cold should be run first then adjusted with hot water.