NU142- Chapter 62: Management of 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."

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

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%

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%

Acticoat antimicrobial barrier dressings used in the treatment of burn wounds can be left in place for which time frame?

5 days

Which of the following is the preferred IV fluid for burn resuscitation?

Lactated Ringer's (LR)

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

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

Mafenide (Sulfamylon)

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

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

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 type of burn is similar to a sunburn?

Superficial partial-thickness

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.

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 of 20 ml/hour

During the acute phase of a burn, a nurse should assess:

circulatory status.

Which is a quick technique to assess the percentage of a burn injury?

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

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

eschar

devitalized tissue resulting from a burn or wound

Which type of graft utilizes the client's own skin for wound coverage?

Autograft

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

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

Biobrane

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.

Which is the primary nursing intervention in the care of a client with burns exceeding 20% of total body surface area?

Fluid resuscitation

Which type of burn injury requires skin grafting?

Full-thickness

The palm represents which percentage of a person's TBSA?

1%

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

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

Application of cool water

A client is brought to the emergency department by a coworker following a burn injury from a high-voltage electrical power line. The triage nurse determines which intervention should be completed first?

Apply a cervical collar on the client

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

Applying knee splints

The nurse is monitoring for fluid and electrolyte changes in the emergent phase of burn injury for a patient. Which of the following will be an expected outcome? Select all that apply.

Base-bicarbonate deficit Elevated hematocrit level Sodium deficit

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.

debridement

removal of foreign material and devitalized tissue until surrounding healthy tissue is exposed

contracture

shrinkage of burn scar through collagen maturation

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.

donor site

the area from which skin is taken to provide a skin graft for another part of the body

What are the expected findings in the fluid remobilization phase (acute phase, diuresis) that the nurse should monitor for? Select all that apply.

Hemodilution Increased urinary output Sodium deficit

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 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 immediately when reviewing laboratory studies?

Hyperkalemia

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.

Which of the following is a true statement regarding the purposes of skin grafts?

Reduces scarring and contractures.

Which of the following topical burn preparations act as wick for sodium and potassium?

Silver nitrate solution

Which of the following are possible indicators of pulmonary damage from an inhalation injury? Select all that apply.

Singed nasal hair Hoarseness Facial burns

The nurse is planning the care of a patient with a major thermal burn. What outcome will the nurse understand will be optimal during fluid replacement?

A urinary output of 30 mL/hr

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

Which complication is common for victims of electrical burns?

Cardiac dysrhythmia

Which of the following is a common complication of an electrical burn injury?

Cardiac dysrhythmias

A nurse knows to assess a patient with a burn injury for gastrointestinal complications. Which of the following is a sign that indicates the presence of a paralytic ileus?

Decreased peristalsis

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 is cared for in a burn unit after suffering partial-thickness burns. The client's laboratory work reveals a positive wound culture for gram-negative bacteria. The health care provider orders silver sulfadiazine to be applied to the client's burns. The nurse provides information to the client about the medication. Which statement made by the client indicates an understanding about this treatment? Select all that apply.

"This medication is an antibacterial." "This medication will be applied directly to the wound." "This medication will help my burn heal."

An emergency department nurse is evaluating a client with partial-thickness burns to the entire surfaces of both legs. Based on the rule of nines, what is the percentage of the body 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 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

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

Hyperkalemia.

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

Hypotension Tachycardia Anxiety

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

Hypovolemia

Which of the following types of shock will a nurse observe in a client with extensive burns?

Hypovolemic shock

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

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

Immerse the child's legs in cool water.

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.

Which of the following would indicate the need to increase fluids beyond what is recommended for fluid resuscitation?

Myoglobin in the urine

Which type of debridement occurs when nonliving tissue sloughs away from uninjured tissues?

Natural

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

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 client who has sustained burns to the anterior chest and upper extremities is brought to the burn center. During the initial stage of assessment, which nursing diagnosis is primary?

Risk for Impaired Gas Exchange

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 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

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

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.

The nurse cares for a 30-year-old client who suffered severe head and facial burn injuries. Which action, if completed by the client, indicates the client is adapting to altered body image? Select all that apply.

Wears hats and wigs Participates actively in daily activities

carboxyhemoglobin

a compound of carbon monoxide and hemoglobin, formed in the blood with exposure to carbon monoxide

autograft

a graft derived from one part of a patient's body and used on another part of that same patient's body

xenograft

a graft obtained from an animal of a species other than that of the recipient (e.g., pigskin) also called heterograft

homograft

a graft transferred from one human (living or cadaveric) to another human also called allograft

excharotomy

a linear excision made through eschar to release constriction of underlying tissue

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 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

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

face, neck, chest

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)

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

inflammatory

fasciotomy

an incision made through the fascia to release constriction of underlying muscle

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.

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

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

Pulmonary system

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

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.

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.

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.

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

a patent airway established.

collagen

a protein present in skin, tendon, bone, cartilage, and connective tissue

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

excision

surgical removal of tissue

Which antimicrobials is not commonly used to treat burns?

tetracycline