Pearson Burns

b

Which of the following refers to a wound covering brought about by the donated human cadaver skin provided by the skin bank? A Autograft. B Homograft. C Heterograft. D Xenograft

c (A heterograft is a dressing for a burn that uses skin obtained from an​ animal, usually a​ pig; this type of dressing needs to be changed frequently and is associated with high rates of infection. A homograft or allograft is human skin that has been harvested from cadavers. Synthetic dressings contain nylon and silicone.)

Which type of dressing for a burn wound uses skin obtained from an​ animal? a Synthetic b Allograft c Heterograft d Homograft

c (Escharotomy is performed at the bedside and without anesthesia since nerve endings have been destroyed by the burn injury. Option A refers to skin autograft. Option B Escharotomy involves making a lengthwise incision through the burn eschar to relieve vasoconstriction. Option D refers to enzymatic debridement.)

A client is prescribed by the physician to undergo an escharotomy. Which of the following statements made by the nurse is true regarding this procedure? A "It is the surgical removal of a thin layer of the client's own unburned skin." B "A lengthwise incision is made through the burn eschar to relieve vasodilation." C "It is performed at the bedside and without anesthesia." D "It is the application of topical enzyme agents directly to the wound, and these agents digest necrotic collagen tissue"

a (Rationale An elastic pressure garment prevents hypertrophic scarring and is worn for up to a year after the burn. If wound care is​ ordered, it is always with sterile gauze and nonadherent dressings. With​ autografting, the grafted site is immobilized until signs of adherence occur. Hydrotherapy is not conducted for​ autografts; it is conducted to remove necrotic tissue.)

A client with an extensive burn injury to the left arm receives an autograft for permanent skin coverage. Which intervention does the nurse include in the plan of​ care? a Application of elastic pressure garment b Wound care with clean gauze and adherent dressings c Implementation of hydrotherapy d Education on​ range-of-motion (ROM) exercises postoperatively

a (Rationale An echocardiogram is not needed to evaluate a client​'s progress after​ burns; an electrocardiogram would be done to evaluate any potential dysrhythmias. Urinalysis would be done to evaluate lipolysis and for the presence of ketones. Serum electrolytes would be monitored because of the fluid shift with clients with burns. Serum creatinine would be monitored to evaluate kidney function.)

A client with deep​ partial-thickness burns over​ 50% of the body is being transferred to the unit. Which diagnostic test would the nurse clarify with the health care​ provider? a Echocardiogram b Serum electrolytes c Serum creatinine d Urinalysis

c (Rationale: The rule of nines is a quick assessment scale used to estimate the extent of burn injury. The body is divided into areas that represent 9% of the body surface area. This client had burns of the following percentages: R arm 9%, L arm 9%, L leg 18%, back 18% for a total of 54%. )

An African American adult client was severely burned in a grass fire resulting in second-degree burns on the left arm, leg, and back as well as third degree burns on the right arm. Using the rule of nines, what is the estimated extent of burns? a 27% b 45% c 54% d 36%

b,c,d (Rationale The older client may have multiple​ pathophysiologies, such as cardiac or renal dysfunction and​ diabetes, which put them at greater risk for injury and burns. The older client is at risk for burns because of an impaired sense of smell. The client may not be able to smell gas or smoke. Older clients have decreased perception of pain and perception to heat and are at risk for burns from hot water.​ Preschool-age clients, not older​ adults, are likely to climb wires and trees. Adolescents are more likely to risk sun exposure than are older adults.)

The community health nurse is planning a program for older adults regarding burn prevention. Which topic should be​ included? (Select all that​ apply.) a Climbing wires and trees b Coexisting disease processes c Impaired sense of smell d Prevention of water scalds e Sun exposure

d (Rationale: Fluid replacement is considered adequate when urine output is 30-50 mL/hr or 0.5 mL/kg/hr, blood pressure is stable, pulses are palpable, central venous pressure (CVP) is 7-10, and potassium level is 3.5-5.3. A clear sensorium is another positive sign of adequate fluid replacement. Weight gain is not an issue with fluid resuscitation. )

During the shock phase of the burn injury in a severely burned client, which assessment findings indicate that the client is receiving adequate fluid volume replacement? a Weak pulses, BP 85/50, pulse 120, and hematocrit 50% b Bounding pulse, rales on expiration, weight gain >5 lb/24 hrs c Restless, confused as to time and place, urine output 20 mL/ hr, and weight gain of 5 lb d Urine output 45 mL/hr, BP 100/60, and oriented to person and place

1 (A sunburn is a superficial thickness burn. Superficial burns damage the top layer of skin. WRONG 2. A superficial partial thickness burn results from flames or scalds. This damages the entire epidermis layer of the skin 3. A deep partial thickness burn can result from contact with hot grease. This affects the deep layers of skin 4. A full thickness burn can result from hot tar contact. This affects the dermis and sometimes the subcutaneous fat layer)

A nurse in a providers office is assessing a client who has severe sunburn. Which of the following classifications should the nurse use to document this burn? 1. Superficial thickness 2. Superficial partial thickness 3. Deep partial thickness 4. Full thickness

c (You would explain to Mr. Pitts that the elastic pressure garment will reduce hypertrophic scarring where the​ allograft, or skin​ graft, has been applied. Using an elastic pressure garment will not reduce the risk of the body rejecting the​ allograft, reduce the risk of infection from an​ allograft, or increase range of motion.)

Mr. Pitts has had an allograft applied to a burn wound on his trunk. His doctor has prescribed an elastic pressure garment for Mr. Ohm to wear for 1 year. Mr. Pitts asks you why he has to wear the pressure garment. Which is your best response when explaining to Mr. Pitts why he has to wear the pressure​ garment? ​a "It will increase your range of​ motion." ​b "It will reduce the risk of​ infection." ​c "It will reduce hypertrophic​ scarring." ​d "It will reduce the risk of​ rejection."

a (Familiarity with the dressing change and practice of sterility by a nurse from the surgery unit will be appropriately used during the float in the burn unit. Options B, C, and D: Admission assessment, splinting and discharge teaching require expertise in caring for burn patients.)

Nurse Kelsey is a nurse manager assigned in the burn unit. Which client is best to assigned to an RN who has floated from the surgery unit? A A client with infected partial-thickness back and chest burns who has a dressing scheduled. B A client who has just been admitted with burns over 30% of the body after a warehouse fire. C A client with full-thickness burns on both arms who needs assistance in positioning hand splints. D A client who requires discharge teaching about nutrition and wound care after having skin grafts.

a,c,e

Rehabilitation is the final phase of the burn care. Which of the following are the goals during this phase? Select all that apply A Provide emotional support. B Prevent hypovolemic shock. C Promote wound healing and proper nutrition. D Fluid replacement. E Help the client in gaining optimal physical functioning.

d (sickle cell)

What additional laboratory test should be performed on any African American client who sustains a serious burn injury? A Total protein B Tissue type antigens C Prostate-specific antigen D Hemoglobin S electrophoresis

b (Maintaining the client​'s limbs in normal functional alignment is an intervention for impaired physical mobility in a client with a burn. Providing enteral or parenteral nutrition as prescribed is an intervention for imbalanced nutrition in a client with a burn. Keeping needed items within reach and allowing the client to control his or her environment are interventions for powerlessness in a client with a burn.)

Which nursing intervention is appropriate for impaired physical mobility from burn​ wounds? a Keep needed items within reach. b Maintain limbs in normal functional alignment. c Provide enteral or parenteral nutrition as prescribed. d Allow the client to control the environment.

a (Rationale Clients with burns or any significant degree of stress are very susceptible to the development of Curling ulcers​ (stress ulcers). An H2receptor antagonist will decrease acid​ secretion, thereby preventing the formation of stress ulcers. An H2receptor antagonist is not used to control moderate pain or to control infection. H2 receptor antagonists are not vitamin​ supplements; they are medications that decrease gastric acid secretion.)

A client being treated for severe burns is prescribed an intravenous H2 blocker every 6 hours. What is the rationale for this​ therapy? a Prevention of gastric hyperacidity b Prevention of infection c Management of moderate pain d Vitamin supplementation

a (Based on the rule of nines, posterior trunk equals 18%, right arm equals 9%, and left posterior leg equals 9%. Therefore, a total of 36%.)

A client is brought to the emergency unit with third-degree burns on the posterior trunk, right arm, and left posterior leg. Using the Rule of Nines, what is the total body surface area that has been burned? A 36%. B 54%. C 45%. D 27%.

a,c,e (The nurse should limit visitors and limit the amount of time they visit to decrease risk of infection. The client should increase protein consumption to help heal and prevent further tissue breakdown. Flowers should not be in the clients room due to the bacteria they carry which increase the risk for infection. WRONG: b Restrict consumption of fresh vegetables due to presence of bacteria and risk of infection. D. Consume 5000 calories a day because caloric needs double or triple beginning 4-12 days following the burn)

A nurse is planning care for an adult client who sustained severe burn injuries. Which of the following interventions should the nurse include in the plan of care? SATA a. limit visitors in the clients room b. encourage fresh vegetables in the diet c. increase protein intake d. instruct the client to consume 2000 cal a day e. Restrict fresh flowers in the room

d (Mrs.​ Kling's decreased urine output and increased serum creatinine and BUN levels could indicate that the burn is affecting her renal system. Renal involvement occurs because blood flow and glomerular filtration rate are reduced because of the drop in circulating fluids. The manifestations of decreased urine output and increased serum creatinine and BUN levels would not indicate that the burn is affecting Mrs.​ Kling's immune,​ digestive, or respiratory system.)

Mrs. Kling is being treated for a major burn. Her test results show that over the past 24​ hours, her urine output has decreased and her serum creatinine and blood urea nitrogen​ (BUN) levels have increased. What could these manifestations indicate about the effect Mrs.​ Kling's burn is having on her​ body? a The burn is affecting her respiratory system. b The burn is affecting her immune system. c The burn is affecting her digestive system. d The burn is affecting her renal system.

d (You would elevate Ms.​ Sorrento's skin graft site​ (her leg) at or above heart level as an appropriate intervention for the problem of impaired skin integrity. Another intervention for this problem would include immobilizing Ms.​ Sorrento's skin graft site for 3 to 5​ days, not 1 to 2 days. Monitoring hourly intake and output and following the fluid resuscitation plan are interventions for deficient fluid​ volume, not impaired skin​ integrity, in a client with a burn such as Ms. Sorrento.)

Ms. Sorrento has recently had a heterograft to treat a burn on her leg. Which intervention should you take to specifically address the problem of impaired skin integrity for Ms.​ Sorrento? a Follow the fluid resuscitation plan for Ms. Sorrento. b Immobilize Ms.​ Sorrento's leg for 1 to 2 days. c Monitor Ms.​ Sorrento's hourly intake and output. d Elevate Ms.​ Sorrento's leg at or above heart level.

a (In the proliferation phase of burn wound​ healing, granulation tissue forms with complete​ re-epithelialization. Platelets aggregate around burned​ tissue, fibrin is​ deposited, and thrombus formation occurs in the inflammation phase of burn wound healing. A hypertrophic scar or an overgrowth of tissue may occur in the remodeling stage of burn wound healing.)

What is a characteristic of the proliferation phase of burn wound​ healing? a Granulation tissue forms with complete​ re-epithelialization. b Fibrin is​ deposited, and thrombus formation occurs. c Hypertrophic scar or an overgrowth of tissue may occur. d Platelets aggregate around burned tissue

b (Rationale: An escharotomy is performed to prevent arterial occlusion and resulting gangrene in a circumferential burn. Skin grafting will probably be necessary and scarring will result. Dead tissue may be excised and scrupulous wound care is necessary to prevent infection)

When caring for a client after an escharotomy, how should the nurse explain to the client the reason for the procedure? a The procedure does not remove any tissue. b The procedure permits blood to flow more easily. c The procedure will prevent infections. d A skin graft will prevent scarring of the area.

c (Option C: Burns of the perineum increase the risk for sepsis. Burns of the hands require special attention to ensure the best functional outcome.)

Which client factors should alert the nurse to potential increased complications with a burn injury? A The client is a 26-year-old male. B The client has had a burn injury in the past. C The burned areas include the hands and perineum. D The burn took place in an open field and ignited the client's clothing.

b,c,d,e (The plan of care for a client with a burn is designed to achieve the goals of adequate fluid​ volume, adequate nutrition to meet body​ needs, adequate pain​ control, and no evidence of infection. The plan of care is also designed to achieve the goal of full range of motion after recovery. Measures are taken to reduce​ scarring, but achieving no scarring after recovery is not a goal that is included in the plan of care for a client with a burn.)

Which goal is included in the plan of care for a client with a​ burn? (Select all that​ apply.) a No scarring after recovery b Adequate pain control c Adequate nutrition to meet body needs d Adequate fluid volume e No evidence of infection

c (Rationale Fluid resuscitation is a priority in the first 24 hours after a burn to prevent the onset of shock and system​ collapse; urine output is the most readily available and reliable indicator for determining the adequacy of fluid replacement. Pain is a high​ priority, but measures to preserve life must be a priority. Assessing for infection is important.​ However, during the shock​ phase, measures to preserve life must be a priority. Hourly ROM cannot occur until after the client is stabilized.)

A client is being treated for​ second- and​ third-degree burns over​ 60% of the body. Fourteen hours​ later, the client is receiving a lactated Ringer solution at 200​ mL/hr. Which intervention is a priority at this​ time? a Assess burned areas for signs and symptoms of infection. b Begin hourly ROM. c Monitor hourly urine output. d Administer morphine sulfate PRN.

a (Rationale: Clients with burns or any significant degree of stress are very susceptible to the development of Curling's ulcers (stress ulcers). Ranitidine is an H2 receptor antagonist and will decrease acid secretion and prevent formation of stress ulcers. It is not used for treatment of gastritis or pain, nor is it a vitamin supplement. )

A client with severe burns is receiving ranitidine hydrochloride (Zantac) 50 mg IV every 6 hours. What is the rationale for this therapy? a Prevention of Curling's ulcers b Management of moderate pain c Vitamin supplementation d Ongoing treatment for a client history of gastritis

c (Rationale: Fluid resuscitation is a priority in the first 24 hours after a burn to prevent the onset of shock and system collapse. Urine output is the most readily available and reliable indicator for determining the adequacy of fluid replacement. Assessing for infection is important, as are pain control and range of motion; however, during the shock phase, adequacy of fluid resuscitation should be the priority. Pain is a high priority after fluid resuscitation has begun. )

A healthcare provider admitted a client with second and third degree burns over 60% of the body. Fourteen hours later, the client is receiving lactated Ringer's at 200 mL/hr. Which intervention is the priority at this time? a Administer morphine sulfate prn. b Assess burned areas for signs and symptoms of infection. c Monitor hourly urine output. d Begin hourly range of motion.

c (Rationale: The discharged client and family must be alert to signs and symptoms of infection and know to notify the physician if they occur. Pressure garments may need to be worn for up to 2 years. A high-protein diet rather than a high-carbohydrate diet is recommended to promote healing and recovery. Cold packs can damage new skin, so they would not be appropriate. )

An adolescent who experienced major burns 2 months ago is ready for discharge. Which is the best statement that reflects the adolescent and her family understand the discharge care? a "I will apply cold packs to my arms three times a day for at least half an hour." b "I really need to stick to the high-carbohydrate, high-calorie diet that I had in the hospital." c "I will call my doctor if I have a fever or my arms have any drainage." d "I will be so glad to be home and not need to wear this pressure covering on my arms anymore."

b (A pain medication is administered prior the dressing change since the type of burn will be painful during the procedure. Then the wound is debrided before getting the sample for culture to prevent other bacteria that can contaminate the actual wound. An antibacterial cream such as silver nitrate is applied to the area to attain the maximum effect of the medication. Lastly, cover the wound using a sterile dressing.)

Nurse Malcolm is performing a sterile dressing change on a client with a superficial partial thickness burn on the shoulder and back. Arrange the steps in the order in which each should be performed? 1. Cover the wound using a sterile gauze dressing. 2. Administer Tramadol (Tramal) 50 mg IV. 3. Debride the wound of eschar using gauze sponges. 4. Apply silver nitrate ointment. 5. Obtain sample for wound culture. A 2,5,4,3,1 B 2,3,5,4,1 C 5,2,3,1,4 D 5,4,3,1,2

c (Question 3 Explanation: Option C: Although providing some pain relief has a high priority, and giving the drug by the IV route instead of IM, SC, or orally does increase the rate of effect, the most important reason is to prevent an overdose from accumulation of drug in the interstitial space during the fluid shift of the emergent phase. When edema is present, cumulative doses are rapidly absorbed when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics.)

The burned client newly arrived from an accident scene is prescribed to receive 4 mg of morphine sulfate by IV push. What is the most important reason to administer the opioid analgesic to this client by the intravenous route? A The medication will be effective more quickly than if given intramuscularly. B It is less likely to interfere with the client's breathing and oxygenation. C The danger of an overdose during fluid remobilization is reduced. D The client delayed gastric emptying

d (Option D: These findings are associated with systemic gram-negative infection and sepsis. This is a medical emergency and requires prompt attention.)

The client, who is 2 weeks postburn with a 40% deep partial-thickness injury, still has open wounds. On taking the morning vital signs, the client is found to have a below-normal temperature, is hypotensive, and has diarrhea. What is the nurse's best action? A Nothing, because the findings are normal for clients during the acute phase of recovery. B Increase the temperature in the room and increase the IV infusion rate. C Assess the client's airway and oxygen saturation. D Notify the burn emergency team.

b (Rationale Nutrition therapy does not indicate the success or failure of fluid resuscitation after a burn injury. Hourly urine output is often used as the indicator of effective fluid​ resuscitation, with about 0.5​ mL/kg/hr or 30 to 50​ mL/hr considered adequate for an adult. Heart rate can be used as an​ indicator; however, it should decrease when the client has adequate fluid​ volume, not show tachycardia. Hypertension is not an indicator of adequate fluid resuscitation.)

The nurse is providing intravenous fluids to a client being treated for a major burn. Which piece of assessment data indicates effective fluid resuscitation for this​ client? a Hypertension b 45 mL of urine output per hour ​c 75% consumption of meal d Tachycardia

d

The nurse manager is observing a new nursing graduate caring for a burned client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which incorrect component of protective isolation technique? A Performing strict handwashing techniques. B Wearing protective garb, including a mask, gloves, cap, shoe covers, gowns, and a plastic apron. C Using sterile bed sheets and linens. D Wearing gloves and a gown only when giving direct care to the client.

a,c,d (Dyspnea can occur during the initial phase following a burn due to airway injury and fluid shifts. Hyperkalemia occurs during the initial phase following a burn as a result of fluid leaking from the intercellular space. Hyponatremia occurs during the initial phase of a burn as a result in sodium retention in the interstitial space. WRONG: b; tachycardia would occur during the initial phase following a burn due to sympathetic nervous system compensation. e: Hct INCREASES during the initial phase of burn due to hemoconcentration.)

A nurse assessing a client who sustained deep partial-thickness and full-thickness burns over 40% of his body 24 hrs ago. Which of the following are findings should the nurse expect? SATA a. dyspnea b. bradycardia c. hyperkalemia d. hyponatremia e. Decreased hematocrit

3 (Wheezing and hoarseness indicate inhalation injury with impending loss of airway. These require immediate reporting to the HCP. WRONG: 1 difficulty breathing and pink frothy sputum would indicate pulmonary edema 2: productive cough and fever would indicate bacterial pneumonia 4: Confusion and headache would indicate carbon monoxide poisoning)

A nurse caring for a client who has sustained burns over 35% of his total body surface area. Of this total 20% are full thickness burns on the arms, face, neck, and shoulders. The clients voice has become hoarse. He has a brassy cough, and is drooling. The nurse should identify these findings as indications that the client has which of the following? 1. pulmonary edema 2. bacterial pneumonia 3. inhalation injury 4. carbon monoxide poisening

b (Rationale The extent of burns is not how many limbs are​ involved; it is the percentage of the body that is burned. The extent of burns is determined by calculating​ BSA; therefore, the nurse educator would not question this statement. The BSA is measured as a percentage and will give a better understanding of how much of the body is affected by the burn. The extent of burns is calculated by the Rule of​ Nines; therefore, the nurse educator would not question this statement. The Rule of Nines measures the BSA by dividing the body into five surface​ areas: the​ head, trunk,​ arms, legs, and perineum. Each surface is assigned a number that is a multiple of nine. The amount is totaled and represents the BSA that is affected. The extent of burns can be calculated by the Lund and Browder​ method; therefore, the nurse educator would not question this statement. The Lund and Browder method determines the BSA by measuring the body part according to the age of the client.)

A nurse educator is educating a student on burns. Which statement made by the student would indicate that further education is​ necessary? ​a "The extent of burns is calculated by the Rule of​ Nines." ​b "The extent of burns is how many limbs are​ involved." ​c "The extent of burns can be calculated by the Lund and Browder​ method." ​d "The extent of burns is expressed as a percentage of body surface area​ (BSA)."

3 (The nurse should use the IV route to administer pain medication for rapid absorption and fast pain relief during the resuscitation phase. WRONG: 1. The nurse should not give SC injections due to the difficulty to absorb from tissue during the resuscitation phase. 2: The nurse should not give PO, buccal or SL meds due to decreased motility in the GI tract during this phase. 4: The nurse should not use transdermal due to delays in absorption during this phase)

A nurse is preparing to administer fentanyl to a client who sustained deep partial-thickness and full thickness burns over 60% of the body 24 hrs ago. The nurse should plan to use which of the following routes to administer the medication? 1. SC 2. Oral 3. IV 4. Transdermal

c (Rationale: The priority is to flush with water to neutralize the chemicals and to decrease a heat reaction. This also decreases the chemical contact time, which is directly related to the degree of injury. It is important to call 911 after beginning the flush of the affected area, because the client has other needs that cannot be managed at the scene. Covering the client or removal from the area will not stop the burn process, so the priority action is to flush the burned area. )

An occupational health nurse arrives at the scene where a client suffered a burn from a chemical splash. What is the priority intervention? a Apply gloves and remove the client from the scene. b Cover the client with a blanket. c Flush the area with copious amounts of water. d Call 911.

c (Burns of the neck and chest are associated with inflammation and swelling of the airway. Hence this patient requires the most immediate attention.)

Nurse Rodrigo is receiving an endorsement from the burn unit. Which of the following clients should he assess first? A A client who has just been transferred from the PACU after having allograft. B A client admitted 1 week ago with a superficial-thickness burn on the buttocks which has been waiting for 2 hours to receive discharge instructions. C A client who has just arrived from the emergency department with burns on the neck and chest. D A client with deep partial-thickness burns on both thighs who is complaining of severe and continuous pain.

a,b,c,e (Rationale Because changes in sensorium will occur within the first few hours after a major burn​ injury, the nurse needs to obtain as much information as possible when the client arrives in the emergency department. The time of injury is important to note because all fluid resuscitation calculations are based on the time of the burn injury. The cause of the injury should be evaluated because this determines the nursing measures​ needed; any first aid treatment given should be documented. The medical staff needs to know what was done to the burn before arriving at the hospital. Body weight is an important assessment because during the acute and rehabilitative phases of​ care, the client will lose up to​ 20% of preburn​ weight, which could have implications for those who might be underweight or cachectic at the time of injury. Range of motion is an important evaluation but is not important in the emergency​ department; rather, it is an important assessment as the tissue heals.)

The emergency department nurse is preparing to assess a client who has sustained a severe burn to the anterior aspects of both legs. Which assessment data would be gathered upon arrival to the emergency care​ center? ​(Select all that​ apply.) a Cause of the injury b First aid treatment provided c Time of the injury d Range of motion e Body weight

a,c,d (Rationale Nursing interventions appropriate during the emergent stage of burn injury​ are: obtaining a​ history, preventing​ hypothermia, and assessing the extent of the burn injury. Nutritional support would start during the acute stage of burn​ injury, and prevention of scar formation would be a focus during the rehabilitative stage.)

The nurse in the intensive care unit​ (ICU) receives a report on a client brought in with severe burns. Which intervention is appropriate for a client in the emergent stage of burn​ injury? ​(Select all that​ apply.) a Prevent hypothermia b Prevent scar formation c Obtain history d Assess extent of burn injury e Start nutrition support

a (Rationale Deep​ partial-thickness burns occur when the skin is burned into the dermis. The hair​ follicles, sebaceous​ glands, and sweat glands are intact. The skin is pale and​ waxy, and dry​ (like tissue​ paper); large blisters develop. The burned areas are less painful and have areas of decreased sensation. Superficial burns are burns to the epidermis. The skin is intact and skin color is pink to bright red in color. Edema is present over the burned​ area, and healing takes place in 3 to 6 days. With​ full-thickness burns, all layers of the​ skin, subcutaneous​ tissue, connective​ tissue, muscle, and bone are involved in the burn. The wound surface is​ dry, with a leathery​ feel, and is firm to touch. The skin is​ pale, waxy​ yellow, brown,​ mottled, or nonblanching​ red; there is no sensation or pain. Superficial​ partial-thickness burns are bright red and moist. There is a blister formation and blanching on pressure. Pain and sensation are intact. There are pigment changes but no scarring.)

The nurse is caring for a client with a burn. The assessment reveals that there are large blisters that are dry like tissue paper with areas of decreased sensation. The burns are pale with a waxy appearance. Which type of burn will the nurse document in the client​'s medical​ record? a Deep partial thickness b Superficial c Full thickness d Superficial partial thickness

c (Rationale By maintaining​ asepsis, the client will have a reduced risk of infection. Fluid resuscitation may not be indicated for a minor burn and will not reduce the client​'s risk for infection. After the client is​ treated, counseling might be appropriate to determine the cause of the burn and to plan​ interventions; however, this will not reduce the client​'s risk for infection. IV narcotics will not reduce the client​'s risk for infection.)

The nurse is caring for an older client being treated for a minor burn that has an increased risk for infection. Which intervention would be appropriate for the nurse to​ provide? a Fluid resuscitation b IV narcotics c Maintain an aseptic environment d Counseling

d (Rationale The characteristic skin surface of a burn is a bull​'​s-eye appearance. Burned skin is not healing appropriately. The loss of skin can lead to rapid evaporation and loss of water and electrolyte and fluid imbalance. Skin is the primary means of protection from infection because of the barrier that it provides. Without the skin or with altered​ skin, clients are at high risk of microorganisms entering tissue and causing infection. Burned skin leaves open​ wounds, and clients can lose heat through these​ wounds, which would contribute to altered body temperature.)

The nurse is educating the client on the loss of skin protection caused by burns. Which statement is not appropriate for the nurse to include in the teaching​ session? ​a "You are at risk for infection because of the loss of skin​ integrity." ​b "You will have a loss of water secondary to​ evaporation." ​c "It may be difficult to maintain temperature because of the loss of heat from the​ burns." d ​"If the skin has a bull​'​s-eye ​appearance, it is healing​ appropriately."

c,e (Rationale: Inhalation injury occurs when smoke or fumes are inhaled. Inhalation injuries may be suspected when there are burns to the upper torso or face, sputum production is decreased even though congestion is present, and the voice is hoarse, or there are blisters or edema in the oropharynx. Decreased level of consciousness is not specific to inhalation burns but to the level of injury overall. )

What assessment and nursing diagnosis would lead the nurse to suspect that an inhalation injury may have occurred in a client with a severe burn? (Select all that apply.) a Increased sputum production b Impaired Gas Exchange and excessive thirst c Risk for Aspiration and hoarse voice d Ineffective Airway Clearance and decreased level of consciousness e Ineffective Airway Clearance and singed hair and eyebrows

c (A​ moist, glistening appearance is a characteristic of a superficial​ partial-thickness burn. A superficial​ burn, not a superficial​ partial-thickness burn, heals in 3 to 6 days. A burn that goes deep into the dermis is a deep​ partial-thickness burn. A​ full-thickness burn will cause no sensation or pain.)

Which is a characteristic of a superficial​ partial-thickness burn? a No sensation or pain b Heals in 3 to 6 days ​c Moist, glistening appearance d Goes deep into the dermis

c (Escharotomy is a surgical intervention used to manage a burn wound. One of the characteristics of escharotomy is an incision made longitudinally along the skin to release taut skin. Surgical debridement is the intervention that excises the wound to the level of fascia and is used for extensive or​ full-thickness burns. Autografting is a surgical intervention in which part of healthy skin is removed and used to cover a burn wound.)

Which is a characteristic of escharotomy as it is used to manage a burn​ wound? a Excising the wound to the level of fascia b Part of healthy skin is removed and used to cover a burn wound c Incision made longitudinally along the skin to release taut skin d Used for extensive or​ full-thickness burns

b,c,d,e (The effects of a major burn on the cardiovascular system include hypovolemic​ shock, cardiac​ dysrhythmias, cardiac​ arrest, and vascular compromise. Atherosclerosis is not one of the effects of a major burn on the cardiovascular system.)

Which is an effect of a major burn on the cardiovascular​ system? (Select all that​ apply.) a Atherosclerosis b Hypovolemic shock c Vascular compromise d Cardiac dysrhythmias e Cardiac arrest