ATI Burns ch. 57

A nurse in an emergency department is reviewing the medical record of a client who has an extensive burn injury. Which of the following laboratory results should the nurse expect? Metabolic alkalosis Hypervolemia Hyperkalemia Low hemoglobin

Hyperkalemia MY ANSWER The nurse should expect a client who has a burn injury to experience hyperkalemia due to the release of potassium from damaged cells.

A nurse in an emergency room is caring a the client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take? Insert an indwelling urinary catheter. Inspect the mouth for signs of inhalation injuries. Administer intravenous pain medication. Draw blood for a complete blood cell (CBC) count.

Inspect the mouth for signs of inhalation injuries. MY ANSWER Since the client sustained burns to the chest and face, there is a possibility that flames and smoke from the client's burning clothes could have caused an inhalation injury. The nurse should inspect the mouth and throat for soot and swelling. Using the airway, breathing, circulation (ABC) priority-setting framework, is the priority concern at this time.

A nurse is caring for a toddler who arrives at the emergency department with burns to his lower legs. Which of the following actions should the nurse take? Apply ice to the burns. Place the child in a tub of cool water. Pour tepid water over the burns. Cover the burns with a blanket.

Pour tepid water over the burns. Tepid water reduces pain and swelling and conducts the heat of the burns away from the skin.

A nurse is preparing to start an IV infusion of lactated Ringer's for a client who sustained a burn injury. The client is prescribed 5,200 mL of fluid over the first 24 hr. How many mL/hr should the nurse set the pump to infuse for the first 8 hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

325ml/hr

A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his chest, abdomen, and upper arms. What is the nurse's priority intervention for this client during the resuscitation of phase of injury? Initiate fluid resuscitation. Medicate for pain. Insert an indwelling urinary catheter. Maintain the airway.

Maintain the airway. Rationale: The client is at risk for respiratory obstruction. Using the airway, breathing, circulation approach to client care is the first action the nurse should take to ensure that the client has a patent airway.

A client who is having burn debridement states, "You are the worst nurse I have ever seen. All you do is hurt me." Which of the following responses should the nurse make? "That's a hurtful thing to say." "Tell me more about that." "Why would you say such a thing?" "Well, that's your opinion."

"Tell me more about that." MY ANSWER This statement asks the client to talk about the problem. The nurse is not threatened and is open to hearing more about the problem. Whether the client's statement is true or false, the client will be able to talk about the feelings that caused the outburst. The nurse will be able to adapt care based upon better input and insight into the client's problem.

A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider? Urinary output 25 mL/hr Difficulty swallowing Heart rate 122/min Pain of 6 on a scale of 0 to 10

Difficulty swallowing Using the airway, breathing, circulation approach to client care, the nurse should determine that the priority finding is difficulty swallowing as this is can be an indication that the client's airway is obstructed.

A nurse is admitting a client who has sustained severe burn injuries in a grease fire. The nurse shades in a diagram indicating the burned surface areas. Using the Rule of Nines, the nurse should estimate that the client has burned what percentage of body surface area? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

31.5%

A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines the nurse should document burns to which percentage of the client's total body surface area (TBSA)? 9 percent 18 percent 36 percent 54 percent

54 percent MY ANSWER Each arm represents 9% of the client's TBSA and each leg represents 18% of the client's TBSA totaling 54%.

A nurse is admitting a client who sustained severe burn injuries. The nurse refers to the rule of nines to determine the total body surface area of the burn injury. What percentage of body surface area should the nurse estimate the client has burned?

54%

A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse perform first? Clean and dress the wound. Administer pain medication. Administer a tetanus booster. Administer IV fluids.

Administer IV fluids. MY ANSWER Using the airway, breathing, circulation framework, the priority action the nurse should take is to initiate fluid resuscitation to maintain blood volume and preserve cardiac output. The nurse can utilize large bore peripheral IV cannulas. However, in extensive burns a central line should be inserted to allow for rapid infusion of fluids.

A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement? BP Heart rate Urine output Weight

Heart rate MY ANSWER When a client's circulating fluid volume is low, the heart rate increases to maintain adequate blood pressure. Therefore, the nurse should identify a decrease in heart rate as in indication of adequate fluid replacement.

A nurse is caring for a preschooler who has a partial-thickness burn on her right forearm. Which of the following findings should the nurse expect? (Select all that apply.) Dry surface Sensitive to touch Wound blanches with pressure Intact epidermis Blisters

Sensitive to touch is correct. A partial-thickness burn is sensitive to touch. Wound blanches with pressure is correct. A partial-thickness burn blanches with pressure. Blisters present on skin is correct. A partial-thickness degree burn has blisters.

A nurse is caring for a client who has an electrical burn. With the client's permission, the nurse is answering questions from the family about his status. Which of the following responses should the nurse make? "He is doing well, although he might be in the hospital for some time." "He has an electrical burn. He is stable, and we will update you with any changes." "He has an electrical burn, which caused coagulation of some tissues." "He does not appear to have much damage and should be fine soon."

"He has an electrical burn. He is stable, and we will update you with any changes." MY ANSWER This response provides concrete information without medical jargon, and offers ongoing support.

A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate? "Large incisions will be made in the eschar to improve circulation." "This procedure involves placing the client into a shower and removing the dead tissue." "A piece of healthy skin will be removed from an unburned area and grafted over the burned area." "Dead tissue will be non-surgically removed."

"Large incisions will be made in the eschar to improve circulation." An escharotomy is a surgical incision made to release pressure and improve circulation in a part of the body that has a deep burn and is experiencing excessive swelling. Burn injuries that encircle a body part, such as an arm or the chest, can cause swelling and tightness in the affected area, resulting in reduced circulation. Making surgical incisions into the burned tissue allows the skin to expand, reduces tightness and pressure, and improves circulation.

A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support? Assign assistive personnel to keep his room neat and clean. Rotate nursing staff so he can have varied interactions. Talk with the client during wound care. Keep family members aware of his condition.

Talk with the client during wound care. MY ANSWER Talking with the client while providing care assists in the development of the nurse-client relationship and demonstrates caring.

A nurse is assessing a client who is brought to the emergency room with burn injuries. Which of the following findings should the nurse identify as a deep partial-thickness burn? The burned area is black in color and pain is absent. The burned area is pink in color with blisters present. The burned area is red in color with eschar present. The burned area is yellow in color with severe edema.

The burned area is red in color with eschar present. This finding indicates a deep partial-thickness burn. Additional findings may include moderate edema and reports of pain. At this stage, the eschar that is present is soft and dry.

A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention? Airway obstruction Infection Fluid imbalance Paralytic ileus

Airway obstruction MY ANSWER When using the airway, breathing, circulation approach to client care, the nurse determines that the priority risk is airway obstruction. Burns of the head, neck, and chest often involve damage to the pulmonary tree due to heat as well as smoke and soot inhalation. This can result in severe respiratory difficulty. Nursing measures to maintain a patent airway should take priority in this client's care.

A nurse is assessing a client following the application of an aquathermia pad. Which of the following is the first indication to the nurse that the client is experiencing a superficial burn injury to the application site? Blistering Erythema Eschar Absence of pain

Erythema MY ANSWER Erythema is an indication that the client has experienced a superficial burn with damage limited to the epidermis. Other manifestations include edema, pain, and increased sensitivity to heat.

A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hr following a burn injury? Dextrose 5% in water Dextrose 5% in 0.9% sodium chloride 0.9% sodium chloride Lactated Ringer's

Lactated Ringer's MY ANSWER Lactated Ringer's is used in the first 24 hr following a burn injury because it is a crystalloid solution whose composition and osmolality most closely resembles plasma.

A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns? Age of the client Associated medical history Location of the burn Cause of the burn

Location of the burn MY ANSWER When using the urgent vs. nonurgent approach to client care, the nurse determines the priority is to assess the location of the burns that can lead to respiratory distress.

A nurse is caring for a client who has full-thickness burns over 75% of his body. The nurse should use which of the following methods to monitor the cardiovascular system? Auscultate cuff blood pressure. Palpate pulse pressure. Obtain a central venous pressure. Monitor the pulmonary artery pressure.

Monitor the pulmonary artery pressure. MY ANSWER Clients who have a large percentage of burned body surface area require critical care and accurate monitoring. The pulmonary artery pressure provides an accurate assessment of the cardiovascular system by detecting changes in both right and left heart pressure which can indicate possible development of pulmonary edema, as well monitor overall fluid status.

A nurse is providing dietary teaching for a client who has a burn injury and adheres to a vegan diet. The nurse should recommend which of the following foods as the best source of protein to promote wound healing? One cup of brown rice One cup of orange juice One cup of pureed avocado One cup of lentils

One cup of lentils MY ANSWER The nurse should determine that nuts and legumes, such as lentils, are the best foods to recommend for protein intake for this client. One cup of lentils contains 17.86 g of protein. A diet high in protein and calories is required to promote wound healing. Nuts and legumes are good sources of protein to include in a plant based diet such as a vegan diet.