PrepU Burn Injury
At the scene of the burn you...
Extinguish/remove from source Cool the burn Remove restrictive objects Cover the wound Irrigate chem burns
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 stain my skin permanently." "This medication will help my burn heal."
Correct response: "This medication is an antibacterial." "This medication will be applied directly to the wound." "This medication will help my burn heal." Explanation: This medication is an antibacterial, which has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. This medication is directly applied to the wound. This medication will not stain the client's skin, but it will help heal the client's burned areas.
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? 9% 18% 27% 36%
Correct response: 27% Explanation: According to the Rule of Nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the client received burns to his back (18%) and one arm (9%), totaling 27% of his body.
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? 18% 27% 30% 36%
Correct response: 36% Explanation: The Rule of Nines divides body surface area into percentages that, when totaled, equal 100%. According to the Rule of Nines, the arms account for 9% each, the anterior legs account for 9% each, and the anterior trunk accounts for 18%. Therefore, this client's burns cover 36% of the body surface area.
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 10 mL/hr A urinary output of 30 mL/hr A urinary output of 80 mL/hr A urinary output of 100 mL/hr
Correct response: A urinary output of 30 mL/hr Explanation: For adults, a urine output of 30 to 50 mL per hour is used as an indication of appropriate resuscitation in thermal and chemical injuries, whereas in electrical injuries a urine output of 75 to 100 mL per hour is the goal (ABA, 2011a).
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 A weight gain of 4 lb (2 kg) in 24 hours Body temperature readings all within normal limits An electrocardiogram (ECG) showing no arrhythmias
Correct response: A urine output consistently above 40 ml/hour Explanation: In a client with burns, the goal of fluid resuscitation is to maintain a mean arterial blood pressure that provides adequate perfusion of vital structures. If the kidneys are adequately perfused, they will produce an acceptable urine output of at least 0.5 ml/kg/hour. Thus, the expected urine output of a 155-lb client is 35 ml/hour, and a urine output consistently above 40 ml/hour is adequate. Weight gain from fluid resuscitation isn't a goal. In fact, a 4-lb weight gain in 24 hours suggests third spacing. Body temperature readings and ECG interpretations may demonstrate secondary benefits of fluid resuscitation but aren't primary indicators.
Which of the following measures can be used to cool a burn? Application of cool water Application of ice directly to burn Wrapping the person in ice Using cold soaks or dressings for at least 1 hour
Correct response: Application of cool water Explanation: Once a burn has been sustained, the application of cool water is the best first-aid measure. Never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns.
Which is the primary nursing intervention in the care of a client with burns exceeding 20% of total body surface area? Prevent infection Fluid resuscitation Endotracheal tube placement Strict intake and output
Correct response: Fluid resuscitation Explanation: Fluid resuscitation requirements are paramount in the management of clients having burns that exceed 20% of TBSA. Fluid resuscitation with crystalloid and colloid solutions is calculated from the time the burn injury occurred to restore the intravascular volume and prevent hypovolemic shock and renal failure. Infection prevention is a care consideration with all burns. Endotracheal tube placement may be necessary if respiratory factors indicate the need. Intake and output records are maintained to determine the success of fluid resuscitation efforts.
Which of the following is to be expected soon after a major burn? Select all that apply. Hypotension Tachycardia Anxiety Hypertension Bradycardia
Correct response: Hypotension Tachycardia Anxiety Explanation: Tachycardia, slight hypotension, and anxiety are expected soon after the burn.
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? Classification by the appearance of blisters Identification by the destruction of the dermis and epidermis Not associated with edema formation Usually very painful because of exposed nerve endings
Correct response: Identification by the destruction of the dermis and epidermis Explanation: Third-degree (full-thickness) burns involve total destruction of the epidermis and dermis and, in some cases, destruction of underlying tissue. Second-degree burns are associated with blister formation.
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 Decreased renal blood flow Fluid loss Sodium and water retention caused by increase adrenocortical activity
Correct response: Liquid blood component is lost into extravascular space Explanation: Hemoconcentration is due to the blood component being lost into the extravascular space. Decreased urinary output occurs secondary to fluid loss, decreased renal blood flow, and sodium and water retention caused by increased adrenocortical activity.
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? Diverticulitis Hematemesis Paralytic ileus Ulcerative colitis
Correct response: Paralytic ileus Explanation: Patients who are critically ill, including those with burns, are predisposed to altered gastrointestinal (GI) motility for many reasons, which may include impaired enteric nerve and smooth muscle function, inflammation, surgery, medications, and impaired tissue perfusion. Three of the most common GI alterations in burn-injured patients are paralytic ileus (absence of intestinal peristalsis), Curling's ulcer, and translocation of bacteria. Decreased peristalsis and bowel sounds are manifestations of paralytic ileus.
Following a burn injury, the nurse determines which area is the priority for nursing assessment? Pulmonary system Cardiovascular system Pain Nutrition
Correct response: Pulmonary system Explanation: Airway patency and breathing must be assessed during the initial minutes of emergency care. Immediate therapy is directed toward establishing an airway and administering humidified 100% oxygen. Pulmonary problems may be caused by the inhalation of heat and/or smoke or edema of the airway. Assessing a patent airway is always a priority after a burn injury followed by breathing. Remember the ABCs.
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 Acute Pain Risk for Infection Alteration in Tissue Perfusion
Correct response: Risk for Impaired Gas Exchange Explanation: During the initial assessment of a burn victim, the nurse must look for evidence of inhalation injury. Once oxygen saturation and respirations are determined, pain intensity is evaluated. The assessment of damage to the tissues and prevention of infection are secondary to airway issues
Which intervention helps to minimize the risk of further injury to an affected person at the scene of a fire? Roll the client in a blanket Cover the client with a wet cloth Place the client with the head positioned slightly below the rest of the body Avoid immediate IV fluid therapy
Correct response: Roll the client in a blanket Explanation: At the scene of a fire, the client should be rolled in a blanket to smother the fire. The client should be placed in a horizontal position to prevent the fire, hot air, and smoke from rising toward the head and entering the respiratory passage. The client should not be covered immediately with a wet cloth or kept in any position other than horizontal. However, IV fluid therapy should be administered en route to the hospital.
The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to increase metabolic rate. increase glucose demands. increase skeletal muscle breakdown. decrease catabolism.
Correct response: decrease catabolism. Explanation: 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. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50%. A marked increase in metabolic rate is seen after a burn injury and interventions are instituted to decrease metabolic rate and catabolism. A marked increase in glucose demand is seen after a burn injury and interventions are instituted to decrease glucose demands and catabolism. Rapid skeletal muscle breakdown with amino acids serving as the energy source is seen after a burn injury and interventions are instituted to decrease catabolism.
