BURNS

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

Immerse the child's legs in cool water. pg. 1815

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 pg. 1808

An emergency room nurse cares for a client admitted with a 50% burn injury at 10:00 this morning. The client weighs 90 kg. Using the Parkland formula, calculate the rate at which the nurse should infuse intravenous fluid resuscitation when started at noon. (Record your answer using a whole number.) _____ mL/hr

1500 mL/hr The Parkland formula is 4 mL/kg/% total body surface area burn. This client needs 18,000 mL of fluid during the first 24 hours postburn. Half of the calculated fluid replacement needs to be administered during the first 8 hours after injury, and half during the next 16 hours. This client was burned at 10:00 AM, and fluid was not started until noon. Therefore, 9000 mL must be infused over the next 6 hours at a rate of 1500 mL/hr to meet the criteria of receiving half the calculated dose during the first 8 postburn hours.

A sample consensus formula for fluid replacement recommends that an isotonic solution be administered in the first 24 hours of a burn in the range of 2 to 4 mL/kg/% of burn with 50% of the total given in the first 8 hours postburn. A 176 lb (80 kg) man with a 30% burn should receive a minimum of how much fluid replacement in the first 8 hours?

2,400 mL pg. 1815

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% pg. 1808

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 pg. 1815

36. Which statement made by the client who experienced burns to the head and neck indicates positive adjustment to the injury? A. "I am planning on cutting the grass in the mornings when the sun isn't as strong." B. "I am working with my family so they can do all of the chores I used to do." C. "I hope the home care nurse can change my dressings so that I do not have to look at my wounds." D. "My wife and I have decided to go to movies instead of baseball games so that people can't see me."

A. "I am planning on cutting the grass in the mornings when the sun isn't as strong."

The client who tripped while carrying an open kettle of hot water received scald burns to the entire chest, the entire anterior section of the right arm, the right half of the abdomen, and the anterior portion of the right leg from the groin to the knee. At what percentage of total body surface area does the nurse calculate the injury using the rule of nines? A. 22% to 23% B. 30% to 31% C. 39% to 40% D. 48% to 49%

A. 22% to 23%

2. An emergency room nurse implements fluid replacement for a client with severe burn injuries. The provider prescribes a liter of 0.9% normal saline to infuse over 1 hour and 30 minutes via gravity tubing with a drip factor of 30 drops/mL. At what rate should the nurse administer the infusion? (Record your answer using a whole number and rounding to the nearest drop.) ____ drops/min

ANS: 333 drops/min 1000 mL divided by 90 minutes, then multiplied by 30 drops, equals 333 drops/min.

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

Application of cool water pg. 1815

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

Applying knee splints pg. 1824

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 pg. 1818

What is the best method to prevent autocontamination for a client with burns? Change gloves when handling wounds on different areas of the body. Ensure that the client is in isolation therapy. Restrict visitors. Use sterile gloves when changing dressings.

Change gloves when handling wounds on different areas of the body. The best way to prevent autocontamination for a burn client is to change gloves when performing wound care on different areas of the body.Isolation therapy methods and restricting visitors are used to prevent cross-contamination, not autocontamination. Using sterile versus clean gloves is a matter of institutional preference and a topic of debate.

The burn client asks the nurse not to remove the loosened bits of skin and tissue during the dressing change, saying "The more skin you take off, the longer it will take me to heal." What is the nurse's best response? A. "Do you want some pain medication before I begin?" B. "The only things I am removing are blocks of bacteria growth, not skin." C. "Don't worry, I have worked the burn unit for years and know what I am doing." D. "This tissue is no longer living and as long as it is present, real healing cannot start."

D. "This tissue is no longer living and as long as it is present, real healing cannot start."

The client is a burn victim who is noted to have increasing edema and decreased urine output as a result of the inflammatory compensation response. What will the nurse do first? A. Administer a diuretic. B. Provide a fluid bolus. C. Recalculate fluid replacement based on time of hospital arrival. D. Titrate fluid replacement.

D. Titrate fluid replacement. Rationale A. A common mistake in treatment is giving diuretics to increase urine output. Diuretics do not increase cardiac output. They actually decrease circulating volume and cardiac output by pulling fluid from the circulating blood volume to enhance diuresis. B. Fluid boluses are avoided because they increase capillary pressure and worsen edema. C. Fluid replacement formulas are calculated from the time of injury, not from the time of arrival at the hospital. D. The intravenous fluid rate should be adjusted on the basis of urine output plus serum electrolyte values (titration of fluids).

Which factors indicate that a client's burn wounds are becoming infected? Select all that apply. Dry, crusty granulation tissue Elevated blood pressure Hypoglycemia Edema of the skin around the wound Tachycardia

Dry, crusty granulation tissue Edema of the skin around the wound Tachycardia Pale, boggy, dry, or crusted granulation tissue is a sign of infection, as is swelling or edema of the skin around the wound. Tachycardia is a systemic sign of infection.Hypotension, not elevated blood pressure, and hyperglycemia, not hypoglycemia, are systemic signs of infection.

A client with burn injuries states, "I feel so helpless." Which nursing intervention is most helpful for this client? Encouraging participation in wound care Encouraging visitors Reassuring the client that he or she will be fine Telling the client that these feelings are normal

Encouraging participation in wound care Encouraging participation in wound care is most helpful in providing the client some sense of control.Encouraging visitors may be a good distraction, but will not help the client achieve a sense of control. Reassuring the client that he or she will be fine is neither helpful nor therapeutic. Telling the client that his or her feelings are normal may be reassuring, but does not address the client's issue of feeling helpless.

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. pg. 1808

A client with burn injuries is admitted. Which priority does the nurse anticipate within the first 24 hours? Range-of-motion exercises Emotional support Fluid resuscitation Sterile dressing changes

Fluid resuscitation During the first 24 hours after a burn injury, the nurse's first priority is to administer fluid resuscitation because fluid does not stay in the vessels after a burn injury.Range-of-motion exercise is not the priority for this client. Although emotional support and sterile dressing changes are important, they are not the priority during the resuscitation phase of burn injury.

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

Fluid resuscitation pg. 1815

A client with partial-thickness burns of the face and chest caused by a campfire is admitted to the burn unit. The nurse plans to carry out which health care provider request first? Give oxygen per facemask. Infuse lactated Ringer's solution at 150 mL/hr. Give morphine sulfate 4 to 10 mg IV for pain control. Insert a 14 Fr retention catheter.

Give oxygen per facemask. The nurse needs to first administer oxygen per face mask to the client. Facial burns are frequently associated with upper airway inflammation. Administration of oxygen will assist in maintaining the client's tissue oxygenation at an optimal level.Although fluid hydration and pain control are important, the nurse's first priority is the client's airway. Monitoring output is important, but the nurse's first priority is the client's airway.

When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority?

Ineffective airway clearance related to edema of the respiratory passages pg. 1813

A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene?

Irrigate the wounds with water. pg. 1814

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

Mafenide (Sulfamylon) pg. 1822

Which of the following is the analgesic of choice for burn pain?

Morphine sulfate pg. 1727

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 pg. 1813

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 pg. 1815

After being exposed to smoke and flames from a house fire, which assessment finding is most important in determining care of the client?

Presence of soot around nasal passages pg. 1812

Which instruction is the most important to give a client who has recently had a skin graft?

Protect the graft from direct sunlight. pg. 1824

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

Reduces scarring and contractures. pg. 1823

Which of the following fluid or electrolyte changes occur in the emergent/resuscitative phase?

Reduction in blood volume pg. 1813

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 pg. 1818

The nurse is evaluating the effectiveness of fluid resuscitation for a client in the resuscitation phase of burn injury. Which finding does the nurse correlate with clinical improvement? Blood urea nitrogen (BUN), 36 mg/dL (12.9 mmol/L) Creatinine, 2.8 mg/dL (248 mcmol/L) Urine output, 40 mL/hr Urine specific gravity, 1.042

Urine output, 40 mL/hr Clinical improvement based on fluid resuscitation for a burn client correlates with a urine output of between 30 and 50 mL/hr or 0.5 mL/kg/hr.A BUN of 36 mg/dL (12.9 mmol/L) is above normal, a creatinine of 2.8 mg/dL (248 mcmol/L) is above normal, and a urine specific gravity of 1.042 is above normal.

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

inflammatory pg. pp. 1810-1811.

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. pg. 1808

A manufacturing plant has exploded, and the nurse is assigned to triage burn victims as they arrive to the hospital. Which is the most important question for the nurse to ask prior to the arrival of victims?

"Are the burns associated with chemicals used in the plant?" pg. 1815

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." pg. 1832

A client with a burn injury due to a house fire is admitted to the burn unit. The client's family asks the nurse why the client received a tetanus toxoid injection on admission. What is the nurse's best response to the client's family member? "The last tetanus injection was less than 5 years ago." "Burn wound conditions promote the growth of Clostridium tetani." "The wood in the fire had many nails, which penetrated the skin." "The injection was prescribed to prevent infection from Pseudomonas."

"Burn wound conditions promote the growth of Clostridium tetani." The nurse's best response is that burn wound conditions promote the growth of Clostridium tetani, and all burn clients are at risk for this dangerous infection. Tetanus toxoid enhances acquired immunity to C. tetani, so this agent is routinely given when the client is admitted to the hospital.Regardless of when the last tetanus injection is given, it is still given on admission to prevent C. tetani. The fact that there were many nails in the wood in the fire is irrelevant. Tetanus toxoid injection does not prevent Pseudomonas infection.

When teaching fire safety to parents at a school function, which advice does the school nurse offer about the placement of smoke and carbon monoxide detectors? "Every bedroom should have a separate smoke detector." "Every room in the house should have a smoke detector." "If you have a smoke detector, you don't need a carbon monoxide detector." "The kitchen and the bedrooms are the only rooms that need smoke detectors."

"Every bedroom should have a separate smoke detector." The school nurse states that every bedroom needs to have a separate smoke detector. All people should be taught to use home smoke detectors and carbon monoxide detectors and to ensure these are in good working order. The number of detectors needed depends on the size of the home.Every room in the house does not need a smoke detector. There should be at least one detector in the hallway of each story, and at least one detector is needed for the kitchen, each stairwell, and each home entrance. Each room that requires a smoke detector should also have a carbon monoxide detector. Carbon monoxide detectors are instrumental in picking up carbon monoxide gas emissions, such as from a defective heating unit.

The nurse is caring for a client who has burns. Which question does the nurse ask the client and family to best assess their coping strategies? "Do you support each other?" "How do you plan to manage this situation?" "How have you handled similar situations?" "Would you like to see a counselor?"

"How have you handled similar situations?" Asking how the client and family have handled similar situations in the past best assesses whether the client's and the family's coping strategies may be effective."Yes-or-no" questions such as "Do you support each other?" are not very effective in extrapolating helpful information. The client and family in this situation probably are overwhelmed and may not know how they will manage. Asking them how they plan to manage the situation does not assess coping strategies. Asking the client and the family if they would like to see a counselor also does not assess their coping strategies.

The nurse is caring for a client who has burns to the face. Which statement by the client requires further evaluation by the nurse? "I am getting used to looking at myself." "I don't know what I will do when people stare at me." "I know that I will never look the way I used to, even after the scars heal." "My spouse does not stare at the scars as much now as in the beginning."

"I don't know what I will do when people stare at me." The statement about not knowing what to do when people stare indicates that the client is not coping effectively. The nurse needs to assist the client in exploring coping techniques. Community reintegration programs can assist the psychosocial and physical recovery of the client with serious burns. Visits from friends and short public appearances before discharge may help the client begin adjusting to this problem.The statement that the client is getting used to looking at himself or herself, the realization that he or she will always look different than before, and stating that the client's spouse does not stare at the scars as much all indicate that the client is coping effectively.

A client who was the sole survivor of a house fire says, "I feel so guilty. Why did I survive?" What is the best response by the nurse? "Do you want to pray about it?" "I know, and you will have to learn to adapt to a new body image." "Tell me more." "There must be a reason."

"Tell me more." Asking the client to tell the nurse more best encourages therapeutic grieving.Offering to pray with the client assumes that prayer is important to the client and does not allow for grieving. The nurse should never assume that the client is religious. The response, "I know, and you will have to learn to adapt to a new body image" only serves to add stress to the client's situation. The response, "There must be a reason," minimizes the grieving process by not allowing the client to express his or her concerns.

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

1% pg. 1809

A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned?

27% pg. 1808

An emergency room nurse implements fluid replacement for a client with severe burn injuries. The provider prescribes a liter of 0.9% normal saline to infuse over 1 hour and 30 minutes via gravity tubing with a drip factor of 30 drops/mL. At what rate should the nurse administer the infusion? (Record your answer using a whole number and rounding to the nearest drop.) ____ drops/min

333 drops/min 1000 mL divided by 90 minutes, then multiplied by 30 drops, equals 333 drops/min.

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 pp. 1814-1815.

When teaching fire safety to parents at a school function, the school nurse offers advice about the placement of smoke and carbon monoxide detectors with which statement? A. "Every bedroom should have a separate smoke detector." B. "Every room in the house should have a smoke detector." C. "If you have a smoke detector, you don't need a carbon monoxide detector." D. "The kitchen and the bedrooms are the only rooms that need smoke detectors."

A. "Every bedroom should have a separate smoke detector." Rationale A. The number of detectors needed depends on the size of the home. Recommendations are that each bedroom should have a separate smoke detector, at least one detector should be placed in the hallway of each floor of the house, and at least one detector is needed for the kitchen, stairway, and home entrance. B. Not every room requires a smoke detector (e.g., the bathroom). C. Carbon monoxide detectors are instrumental in picking up other types of CO gas, such as from a defective heating unit. D. Other rooms, in addition to the kitchen and bedrooms, need smoke detectors.

The client with 45% burns has a hematocrit of 52% 10 hours after the burn injury and 6 hours after fluid resuscitation was started. What is the nurse's best action? A. Assess the client's blood pressure and urine output. B. Notify the physician or the Rapid Response Team. C. Document the report as the only action. D. Increase the IV infusion rate.

A. Assess the client's blood pressure and urine output. Rationale: The massive fluid shift causes hemoconcentration of the cells in the blood. The first action needed is to assess whether the fluid resuscitation at the current rate is adequate. The best ways to determine adequacy by noninvasive measures is by blood pressure measurement and hourly urine output. If fluid resuscitation is adequate, no other action is needed. If blood pressure and urine output indicate fluid resuscitation at the current rate is not adequate, it may need adjustment and the physician should be called.

What is the best method to prevent autocontamination for the client with burns? A. Change gloves when handling wounds on different areas of the body. B. Ensure that the client is in isolation therapy. C. Restrict visitors. D. Watch for early signs of infection.

A. Change gloves when handling wounds on different areas of the body. Rationale A. Gloves should be changed when wounds on different areas of the body are handled and between handling old and new dressings. B. Isolation therapy methods are used to prevent cross-contamination, not autocontamination. C. Restricting visitors helps prevent cross-contamination, not autocontamination. D. Watching for early signs of infection does not prevent contamination.

Which factors indicate that the client's burn wounds are becoming infected? Select all that apply. A. Dry, crusty granulation tissue B. Elevated blood pressure C. Hypoglycemia D. Swelling of the skin around the wound E. Tachycardia

A. Dry, crusty granulation tissue D. Swelling of the skin around the wound E. Tachycardia Rationale Hypotension is a systemic sign of infection.

The client with burn injuries states, "I feel so helpless." Which nursing intervention is most helpful for this client? A. Encouraging participation in wound care B. Encouraging visitors C. Reassuring the client that he or she will be fine D. Telling the client that these feelings are normal

A. Encouraging participation in wound care Rationale A. Encouraging participation in wound care will offer the client some sense of control. B. Encouraging visitors may be a good distraction but will not help the client achieve a sense of control. C. Reassuring the client that he or she will be fine is neither helpful nor therapeutic. It does nothing to help the client achieve a sense of control. D. Telling the client that his or her feelings are normal may be reassuring but does not address the issue of restoring a sense of control.

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 pg. 1812

The nurse is reviewing a medication record for an older adult client recently admitted to the burn unit with severe burns to the upper body from a house fire. The nurse plans to contact the health care provider if the client is receiving which medication? A. Furosemide (Lasix) B. Digoxin (Lanoxin) C. Dopamine (Inotropin) D. Morphine sulfate

A. Furosemide (Lasix) Rationale A. Furosemide, a diuretic, generally is not given to improve urine output for burn clients. Diuretics decrease circulating volume and cardiac output by pulling fluid from the circulating blood to enhance diuresis. This reduces blood flow to other vital organs. B. Digoxin may be used to strengthen the force of myocardial contractions in older adult clients. C. Dopamine may be given to increase cardiac output in older adult clients. D. Morphine sulfate may be indicated for pain management.

A client with partial-thickness wounds of the face and chest caused by a campfire is admitted to the burn unit. The nurse plans to carry out which physician request first? A. Give oxygen per non-rebreather mask at 100% FiO2. B. Infuse lactated Ringer's solution at 150 mL/hr. C. Give morphine sulfate 4 to 10 mg IV for pain control. D. Insert a 14 Fr retention catheter.

A. Give oxygen per non-rebreather mask at 100% FiO2. Rationale A. Facial burns are frequently associated with upper airway inflammation. Administration of oxygen will assist in maintaining the client's tissue oxygenation at an optimal level. B. Although fluid hydration is important, the nurse's first priority is the client's airway. C. Pain control is important, but the nurse's first priority is the client's airway. D. Monitoring output is important, bt the nurse's first priority is the client's airway.

To position the client's burned upper extremities appropriately, how will the nurse position the client's elbow? A. In a neutral position B. In a position of comfort C. Slightly flexed D. Slightly hyperextended

A. In a neutral position Rationale A. The neutral position is the correct placement of the elbow to prevent contracture development. B. Placing the elbow in a position of comfort is not the best placement because the client then usually wants to flex the joint, which increases the risk for contracture development. C. The slightly flexed position increases the risk for contracture development. D. The slightly hyperextended position is not indicated and can be painful.

The newly admitted client has deep partial-thickness burns. The nurse expects to see which clinical manifestations? A. Painful red and white blisters B. Painless, brownish-yellow eschar C. Painful reddened blisters D. Painless black skin with eschar

A. Painful red and white blisters Rationale A. Painful red and white blisters accompany a deep partial-thickness burn. B. Painless, brownish-yellow eschar accompanies a full-thickness burn. C. A painful reddened blister accompanies a superficial partial-thickness burn. D. Painless black skin with eschar accompanies a deep full-thickness burn.

The nurse is caring for a client with a burn injury who is receiving sulfadiazine (Silvadene) to the burn wounds. Which best describes the goal of topical antimicrobials? A. Reduction of bacterial growth in the wound and prevention of systemic sepsis B. Prevention of cross-contamination from other clients in the unit C. Enhanced cell growth D. Reduced need for a skin graft

A. Reduction of bacterial growth in the wound and prevention of systemic sepsis Rationale A. Topical antimicrobials such as sulfadiazine are an important intervention for infection prevention in burn wounds. B. Topical antimicrobials such as sulfadiazine do not prevent cross-contamination from other clients in the unit. C. Topical antimicrobials such as sulfadiazine do not enhance cell growth. D. Use of topical antimicrobials such as sulfadiazine does not minimize the need for a skin graft.

SHORT ANSWER 1. An emergency room nurse cares for a client admitted with a 50% burn injury at 10:00 this morning. The client weighs 90 kg. Using the Parkland formula, calculate the rate at which the nurse should infuse intravenous fluid resuscitation when started at noon. (Record your answer using a whole number.) _____ mL/hr

ANS: 1500 mL/hr The Parkland formula is 4 mL/kg/% total body surface area burn. This client needs 18,000 mL of fluid during the first 24 hours postburn. Half of the calculated fluid replacement needs to be administered during the first 8 hours after injury, and half during the next 16 hours. This client was burned at 10:00 AM, and fluid was not started until noon. Therefore, 9000 mL must be infused over the next 6 hours at a rate of 1500 mL/hr to meet the criteria of receiving half the calculated dose during the first 8 postburn hours.

An emergency room nurse assesses a client who was rescued from a home fire. The client suddenly develops a loud, brassy cough. Which action should the nurse take first? a.Apply oxygen and continuous pulse oximetry. b.Provide small quantities of ice chips and sips of water. c.Request a prescription for an antitussive medication. d.Ask the respiratory therapist to provide humidified air.

ANS: A Brassy cough and wheezing are some of the signs seen with inhalation injury. The first action by the nurse is to give the client oxygen. Clients with possible inhalation injury also need continuous pulse oximetry. Ice chips and humidified room air will not help the problem, and antitussives are not warranted.

A nurse cares for a client with burn injuries. Which intervention should the nurse implement to appropriately reduce the client's pain? a.Administer the prescribed intravenous morphine sulfate. b.Apply ice to skin around the burn wound for 20 minutes. c.Administer prescribed intramuscular ketorolac (Toradol). d.Decrease tactile stimulation near the burn injuries.

ANS: A Drug therapy for pain management requires opioid and nonopioid analgesics. The IV route is used because of problems with absorption from the muscle and the stomach. For the client to avoid shivering, the room must be kept warm, and ice should not be used. Ice would decrease blood flow to the area. Tactile stimulation can be used for pain management.

The nurse assesses a client who has a severe burn injury. Which statement indicates the client understands the psychosocial impact of a severe burn injury? a."It is normal to feel some depression." b."I will go back to work immediately." c."I will not feel anger about my situation." d."Once I get home, things will be normal."

ANS: A During the recovery period, and for some time after discharge from the hospital, clients with severe burn injuries are likely to have psychological problems that require intervention. Depression is one of these problems. Grief, loss, anxiety, anger, fear, and guilt are all normal feelings that can occur. Clients need to know that problems of physical care and psychological stresses may be overwhelming.

A nurse administers topical gentamicin sulfate (Garamycin) to a client's burn injury. Which laboratory value should the nurse monitor while the client is prescribed this therapy? a.Creatinine b.Red blood cells c.Sodium d.Magnesium

ANS: A Gentamicin is nephrotoxic, and sufficient amounts can be absorbed through burn wounds to affect kidney function. Any client receiving gentamicin by any route should have kidney function monitored. Topical gentamicin will not affect the red blood cell count or the sodium or magnesium levels.

A nurse delegates hydrotherapy to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this activity? a."Keep the water temperature constant when showering the client." b."Assess the wound beds during the hydrotherapy treatment." c."Apply a topical enzyme agent after bathing the client." d."Use sterile saline to irrigate and clean the client's wounds."

ANS: A Hydrotherapy is performed by showering the client on a special shower table. The UAP should keep the water temperature constant. This process allows the nurse to assess the wound beds, but a UAP cannot complete this act. Topical enzyme agents are not part of hydrotherapy. The irrigation does not need to be done with sterile saline.

7. An emergency room nurse assesses a client who was rescued from a home fire. The client suddenly develops a loud, brassy cough. Which action should the nurse take first? a. Apply oxygen and continuous pulse oximetry. b. Provide small quantities of ice chips and sips of water. c. Request a prescription for an antitussive medication. d. Ask the respiratory therapist to provide humidified air.

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

Hypotension Tachycardia Anxiety pg. 1827

15. A nurse cares for a client with burn injuries. Which intervention should the nurse implement to appropriately reduce the clients pain? a. Administer the prescribed intravenous morphine sulfate. b. Apply ice to skin around the burn wound for 20 minutes. c. Administer prescribed intramuscular ketorolac (Toradol). d. Decrease tactile stimulation near the burn injuries.

6. The nurse assesses a client who has a severe burn injury. Which statement indicates the client understands the psychosocial impact of a severe burn injury? a. It is normal to feel some depression. b. I will go back to work immediately. c. I will not feel anger about my situation. d. Once I get home, things will be normal.

14. A nurse administers topical gentamicin sulfate (Garamycin) to a clients burn injury. Which laboratory value should the nurse monitor while the client is prescribed this therapy? a. Creatinine b. Red blood cells c. Sodium d. Magnesium

21. A nurse delegates hydrotherapy to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this activity? a. Keep the water temperature constant when showering the client. b. Assess the wound beds during the hydrotherapy treatment. c. Apply a topical enzyme agent after bathing the client. d. Use sterile saline to irrigate and clean the clients wounds.

A nurse cares for a client with burn injuries during the resuscitation phase. Which actions are priorities during this phase? (Select all that apply.) a.Administer analgesics. b.Prevent wound infections. c.Provide fluid replacement. d.Decrease core temperature. e.Initiate physical therapy.

ANS: A, B, C Nursing priorities during the resuscitation phase include securing the airway, supporting circulation and organ perfusion by fluid replacement, keeping the client comfortable with analgesics, preventing infection through careful wound care, maintaining body temperature, and providing emotional support. Physical therapy is inappropriate during the resuscitation phase but may be initiated after the client has been stabilized.

1. A nurse cares for a client with burn injuries during the resuscitation phase. Which actions are priorities during this phase? (Select all that apply.) a. Administer analgesics. b. Prevent wound infections. c. Provide fluid replacement. d. Decrease core temperature. e. Initiate physical therapy.

A nurse cares for a client with burn injuries who is experiencing anxiety and pain. Which nonpharmacologic comfort measures should the nurse implement? (Select all that apply.) a.Music as a distraction b.Tactile stimulation c.Massage to injury sites d.Cold compresses e Increasing client control

ANS: A, B, E Nonpharmacologic comfort measures for clients with burn injuries include music therapy, tactile stimulation, massaging unburned areas, warm compresses, and increasing client control.

A nurse plans care for a client with burn injuries. Which interventions should the nurse implement to prevent infection in the client? (Select all that apply.) a.Ask all family members and visitors to perform hand hygiene before touching the client. b.Carefully monitor burn wounds when providing each dressing change. c.Clean equipment with alcohol between uses with each client on the unit. d.Allow family members to only bring the client plants from the hospital's gift shop. e.Use aseptic technique and wear gloves when performing wound care.

ANS: A, B, E To prevent infection in a client with burn injuries the nurse should ensure everyone performs hand hygiene, monitor wounds for signs of infection, and use aseptic technique, including wearing gloves when performing wound care. The client should have disposable equipment that is not shared with another client, and plants should not be allowed in the client's room.

2. A nurse cares for a client with burn injuries who is experiencing anxiety and pain. Which nonpharmacologic comfort measures should the nurse implement? (Select all that apply.) a. Music as a distraction b. Tactile stimulation c. Massage to injury sites d. Cold compresses e. Increasing client control

ANS: A, B, E Nonpharmacologic comfort measures for clients with burn injuries include music therapy, tactile stimulation, massaging unburned areas, warm compresses, and increasing client control.

5. A nurse plans care for a client with burn injuries. Which interventions should the nurse implement to prevent infection in the client? (Select all that apply.) a. Ask all family members and visitors to perform hand hygiene before touching the client. b. Carefully monitor burn wounds when providing each dressing change. c. Clean equipment with alcohol between uses with each client on the unit. d. Allow family members to only bring the client plants from the hospitals gift shop. e. Use aseptic technique and wear gloves when performing wound care.

A nurse cares for an older client with burn injuries. Which age-related changes are paired appropriately with their complications from the burn injuries? (Select all that apply.) a.Slower healing time - Increased risk for loss of function from contracture formation b.Reduced inflammatory response - Deep partial-thickness wound with minimal exposure c.Reduced thoracic compliance - Increased risk for atelectasis d.High incidence of cardiac impairments - Increased risk for acute kidney injury e.Thinner skin - May not exhibit a fever when infection is present

ANS: A, C, D Slower healing time will place the older adult client at risk for loss of function from contracture formation due to the length of time needed for the client to heal. A pre-existing cardiac impairment increases risk for acute kidney injury from decreased renal blood flow, and reduced thoracic compliance places the client at risk for atelectasis. Reduced inflammatory response places the client at risk for infection without a normal response, including fever. Clients with thinned skin are at greater risk for deeper wounds from minimal exposure.

4. A nurse cares for an older client with burn injuries. Which age-related changes are paired appropriately with their complications from the burn injuries? (Select all that apply.) a. Slower healing time Increased risk for loss of function from contracture formation b. Reduced inflammatory response Deep partial-thickness wound with minimal exposure c. Reduced thoracic compliance Increased risk for atelectasis d. High incidence of cardiac impairments Increased risk for acute kidney injury e. Thinner skin May not exhibit a fever when infection is present

A nurse plans care for a client with burn injuries. Which interventions should the nurse include in this client's plan of care to ensure adequate nutrition? (Select all that apply.) a.Provide at least 5000 kcal/day. b.Start an oral diet on the first day. c.Administer a diet high in protein. d.Collaborate with a registered dietitian. e.Offer frequent high-calorie snacks.

ANS: A, C, D, E A client with a burn injury needs a high-calorie diet, including at least 5000 kcal/day and frequent high-calorie snacks. The nurse should collaborate with a registered dietitian to ensure the client receives a high-calorie and high-protein diet required for wound healing. Oral diet therapy should be delayed until GI motility resumes.

3. A nurse plans care for a client with burn injuries. Which interventions should the nurse include in this clients plan of care to ensure adequate nutrition? (Select all that apply.) a. Provide at least 5000 kcal/day. b. Start an oral diet on the first day. c. Administer a diet high in protein. d. Collaborate with a registered dietitian. e. Offer frequent high-calorie snacks.

A nurse assesses a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which assessment finding should alert the nurse to a potential complication? a.Partial pressure of arterial oxygen (PaO2) of 80 mm Hg b.Urine output of 20 mL/hr c.Productive cough with white pulmonary secretions d.Core temperature of 100.6° F (38° C)

ANS: B A significant loss of fluid occurs with burn injuries, and fluids must be replaced to maintain hemodynamics. If fluid replacement is not adequate, the client may become hypotensive and have decreased perfusion of organs, including the brain and kidneys. A low urine output is an indication of poor kidney perfusion. The other manifestations are not complications of burn injuries.

The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by autocontamination? a.Use a disposable blood pressure cuff to avoid sharing with other clients. b.Change gloves between wound care on different parts of the client's body. c.Use the closed method of burn wound management for all wound care. d.Advocate for proper and consistent handwashing by all members of the staff.

ANS: B Autocontamination is the transfer of microorganisms from one area to another area of the same client's body, causing infection of a previously uninfected area. Although all techniques listed can help reduce the risk for infection, only changing gloves between performing wound care on different parts of the client's body can prevent autocontamination.

A nurse receives new prescriptions for a client with severe burn injuries who is receiving fluid resuscitation per the Parkland formula. The client's urine output continues to range from 0.2 to 0.25 mL/kg/hr. Which prescription should the nurse question? a.Increase intravenous fluids by 100 mL/hr. b.Administer furosemide (Lasix) 40 mg IV push. c.Continue to monitor urine output hourly. d.Draw blood for serum electrolytes STAT.

ANS: B The plan of care for a client with a burn includes fluid and electrolyte resuscitation. Furosemide would be inappropriate to administer. Postburn fluid needs are calculated initially by using a standardized formula such as the Parkland formula. However, needs vary among clients, and the final fluid volume needed is adjusted to maintain hourly urine output at 0.5 mL/kg/hr. Based on this client's inadequate urine output, fluids need to be increased, urine output needs to be monitored hourly, and electrolytes should be evaluated to ensure appropriate fluids are being infused.

A nurse cares for a client with burn injuries from a house fire. The client is not consistently oriented and reports a headache. Which action should the nurse take? a.Increase the client's oxygen and obtain blood gases. b.Draw blood for a carboxyhemoglobin level. c.Increase the client's intravenous fluid rate. d.Perform a thorough Mini-Mental State Examination.

ANS: B These manifestations are consistent with moderated carbon monoxide poisoning. This client is at risk for carbon monoxide poisoning because he or she was in a fire in an enclosed space. The other options will not provide information related to carbon monoxide poisoning.

20. A nurse assesses a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which assessment finding should alert the nurse to a potential complication? a. Partial pressure of arterial oxygen (PaO2) of 80 mm Hg b. Urine output of 20 mL/hr c. Productive cough with white pulmonary secretions d. Core temperature of 100.6 F (38 C)

2. The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by autocontamination? a. Use a disposable blood pressure cuff to avoid sharing with other clients. b. Change gloves between wound care on different parts of the clients body. c. Use the closed method of burn wound management for all wound care. d. Advocate for proper and consistent handwashing by all members of the staff.

ANS: B Autocontamination is the transfer of microorganisms from one area to another area of the same clients body, causing infection of a previously uninfected area. Although all techniques listed can help reduce the risk for infection, only changing gloves between performing wound care on different parts of the clients body can prevent autocontamination

10. A nurse receives new prescriptions for a client with severe burn injuries who is receiving fluid resuscitation per the Parkland formula. The clients urine output continues to range from 0.2 to 0.25 mL/kg/hr. Which prescription should the nurse question? a. Increase intravenous fluids by 100 mL/hr. b. Administer furosemide (Lasix) 40 mg IV push. c. Continue to monitor urine output hourly. d. Draw blood for serum electrolytes STAT.

ANS: B The plan of care for a client with a burn includes fluid and electrolyte resuscitation. Furosemide would be inappropriate to administer. Postburn fluid needs are calculated initially by using a standardized formula such as the Parkland formula. However, needs vary among clients, and the final fluid volume needed is adjusted to maintain hourly urine output at 0.5 mL/kg/hr. Based on this clients inadequate urine output, fluids need to be increased, urine output needs to be monitored hourly, and electrolytes should be evaluated to ensure appropriate fluids are being infused.

16. A nurse cares for a client with burn injuries from a house fire. The client is not consistently oriented and reports a headache. Which action should the nurse take? a. Increase the clients oxygen and obtain blood gases. b. Draw blood for a carboxyhemoglobin level. c. Increase the clients intravenous fluid rate. d. Perform a thorough Mini-Mental State Examination.

A nurse uses the rule of nines to assess a client with burn injuries to the entire back region and left arm. How should the nurse document the percentage of the client's body that sustained burns? a.9% b.18% c.27% d.36%

ANS: C 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 the back (18%) and one arm (9%), totaling 27% of the body.

The nurse teaches burn prevention to a community group. Which statement by a member of the group should cause the nurse the greatest concern? a."I get my chimney swept every other year." b."My hot water heater is set at 120 degrees." c."Sometimes I wake up at night and smoke." d."I use a space heater when it gets below zero."

ANS: C House fires are a common occurrence and often lead to serious injury or death. The nurse should be most concerned about a person who wakes up at night and smokes. The nurse needs to question this person about whether he or she gets out of bed to do so, or if this person stays in bed, which could lead to falling back asleep with a lighted cigarette. Although it is recommended to have chimneys swept every year, skipping a year does not pose as much danger as smoking in bed, particularly if the person does not burn wood frequently. Water heaters should be set below 140° F. Space heaters should be used with caution, and the nurse may want to ensure that the person does not allow it to get near clothing or bedding.

A nurse assesses a client who has a burn injury. Which statement indicates the client has a positive perspective of his or her appearance? a."I will allow my spouse to change my dressings." b."I want to have surgical reconstruction." c."I will bathe and dress before breakfast." d."I have secured the pressure dressings as ordered."

ANS: C Indicators that the client with a burn injury has a positive perception of his or her appearance include a willingness to touch the affected body part. Self-care activities such as morning care foster feelings of self-worth, which are closely linked to body image. Allowing others to change the dressing and discussing future reconstruction would not indicate a positive perception of appearance. Wearing the dressing will assist in decreasing complications but will not enhance self-perception.

A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first? a.Assess the level of consciousness and pupillary reactions. b.Ascertain the time food or liquid was last consumed. c.Auscultate breath sounds over the trachea and bronchi. d.Measure abdominal girth and auscultate bowel sounds

ANS: C Inhalation injuries are present in 7% of clients admitted to burn centers. Drooling and difficulty swallowing can mean that the client is about to lose his or her airway because of this injury. Absence of breath sounds over the trachea and bronchi indicates impending airway obstruction and demands immediate intubation. Knowing the level of consciousness is important in assessing oxygenation to the brain. Ascertaining the time of last food intake is important in case intubation is necessary (the nurse will be more alert for signs of aspiration). However, assessing for air exchange is the most important intervention at this time. Measuring abdominal girth is not relevant in this situation.

A nurse cares for a client who has facial burns. The client asks, "Will I ever look the same?" How should the nurse respond? a."With reconstructive surgery, you can look the same." b."We can remove the scars with the use of a pressure dressing." c."You will not look exactly the same but cosmetic surgery will help." d."You shouldn't start worrying about your appearance right now."

ANS: C Many clients have unrealistic expectations of reconstructive surgery and envision an appearance identical or equal in quality to the preburn state. The nurse should provide accurate information that includes something to hope for. Pressure dressings prevent further scarring; they cannot remove scars. The client and the family should be taught the expected cosmetic outcomes.

After assessing an older adult client with a burn wound, the nurse documents the findings as follows: Heart rate: 110 beats/min Blood pressure: 112/68 mm Hg Respiratory rate: 20 breaths/min Oxygen saturation: 94% Pain: 3/10 Red blood cell count: 5,000,000/mm3 White blood cell count: 10,000/mm3 Platelet count: 200,000/mm3 Left chest burn wound, 3 cm ´ 2.5 cm ´ 0.5 cm, wound bed pale, surrounding tissues with edema present Based on the documented data, which action should the nurse take next? a.Assess the client's skin for signs of adequate perfusion. b.Calculate intake and output ratio for the last 24 hours. c.Prepare to obtain blood and wound cultures. d.Place the client in an isolation room.

ANS: C Older clients have a decreased immune response, so they may not exhibit signs that their immune system is actively fighting an infection, such as fever or an increased white blood cell count. They also are at higher risk for sepsis arising from a localized wound infection. The burn wound shows signs of local infection, so the nurse should assess for this and for systemic infection before the client manifests sepsis. Placing the client in an isolation room, calculating intake and output, and assessing the client's skin should all be implemented but these actions do not take priority over determining whether the client has an infection.

A nurse teaches a client being treated for a full-thickness burn. Which statement should the nurse include in this client's discharge teaching? a."You should change the batteries in your smoke detector once a year." b."Join a program that assists burn clients to reintegration into the community." c."I will demonstrate how to change your wound dressing for you and your family." d."Let me tell you about the many options available to you for reconstructive surgery."

ANS: C Teaching clients and family members to perform care tasks such as dressing changes is critical for the progressive goal toward independence for the client. All of the other options are important in the rehabilitation stage. However, dressing changes have priority.

A nurse reviews the following data in the chart of a client with burn injuries: 36-year-old female with bilateral leg burns NKDA Health history of asthma and seasonal allergies Bilateral leg burns present with a white and leather-like appearance. No blisters or bleeding present. Client rates pain 2/10 on a scale of 0-10. Based on the data provided, how should the nurse categorize this client's injuries? a.Partial-thickness deep b.Partial-thickness superficial c.Full thickness d.Superficial

ANS: C The characteristics of the client's wounds meet the criteria for a full-thickness injury: color that is black, brown, yellow, white, or red; no blisters; minimal pain; and firm and inelastic outer layer. Partial-thickness superficial burns appear pink to red and are painful. Partial-thickness deep burns are deep red to white and painful. Superficial burns are pink to red and are also painful.

A nurse reviews the laboratory results for a client who was burned 24 hours ago. Which laboratory result should the nurse report to the health care provider immediately? a.Arterial pH: 7.32 b.Hematocrit: 52% c.Serum potassium: 6.5 mEq/L d.Serum sodium: 131 mEq/L

ANS: C The serum potassium level is changed to the degree that serious life-threatening responses could result. With such a rapid rise in potassium level, the client is at high risk for experiencing severe cardiac dysrhythmias and death. All the other findings are abnormal but do not show the same degree of severity; they would be expected in the emergent phase after a burn injury.

A nurse prepares to administer intravenous cimetidine (Tagamet) to a client who has a new burn injury. The client asks, "Why am I taking this medication?" How should the nurse respond? a."Tagamet stimulates intestinal movement so you can eat more." b."It improves fluid retention, which helps prevent hypovolemic shock." c."It helps prevent stomach ulcers, which are common after burns." d."Tagamet protects the kidney from damage caused by dehydration."

ANS: C Ulcerative gastrointestinal disease (Curling's ulcer) may develop within 24 hours after a severe burn as a result of increased hydrochloric acid production and a decreased mucosal barrier. This process occurs because of the sympathetic nervous system stress response. Cimetidine is a histamine2 blocker and inhibits the production and release of hydrochloric acid. Cimetidine does not affect intestinal movement and does not prevent hypovolemic shock or kidney damage.

19. A nurse uses the rule of nines to assess a client with burn injuries to the entire back region and left arm. How should the nurse document the percentage of the clients body that sustained burns? a. 9% b. 18% c. 27% d. 36%

3. The nurse teaches burn prevention to a community group. Which statement by a member of the group should cause the nurse the greatest concern? a. I get my chimney swept every other year. b. My hot water heater is set at 120 degrees. c. Sometimes I wake up at night and smoke. d. I use a space heater when it gets below zero.

ANS: C House fires are a common occurrence and often lead to serious injury or death. The nurse should be most concerned about a person who wakes up at night and smokes. The nurse needs to question this person about whether he or she gets out of bed to do so, or if this person stays in bed, which could lead to falling back asleep with a lighted cigarette. Although it is recommended to have chimneys swept every year, skipping a year does not pose as much danger as smoking in bed, particularly if the person does not burn wood frequently. Water heaters should be set below 140 F. Space heaters should be used with caution, and the nurse may want to ensure that the person does not allow it to get near clothing or bedding.

5. A nurse assesses a client who has a burn injury. Which statement indicates the client has a positive perspective of his or her appearance? a. I will allow my spouse to change my dressings. b. I want to have surgical reconstruction. c. I will bathe and dress before breakfast. d. I have secured the pressure dressings as ordered.

ANS: C Indicators that the client with a burn injury has a positive perception of his or her appearance include a willingness to touch the affected body part. Self-care activities such as morning care foster feelings of selfworth, which are closely linked to body image. Allowing others to change the dressing and discussing future reconstruction would not indicate a positive perception of appearance. Wearing the dressing will assist in decreasing complications but will not enhance self-perception.

9. A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first? a. Assess the level of consciousness and pupillary reactions. b. Ascertain the time food or liquid was last consumed. c. Auscultate breath sounds over the trachea and bronchi. d. Measure abdominal girth and auscultate bowel sounds.

4. A nurse cares for a client who has facial burns. The client asks, Will I ever look the same? How should the nurse respond? a. With reconstructive surgery, you can look the same. b. We can remove the scars with the use of a pressure dressing. c. You will not look exactly the same but cosmetic surgery will help. d. You shouldnt start worrying about your appearance right now.

23. After assessing an older adult client with a burn wound, the nurse documents the findings as follows: Vital Signs Laboratory Results Wound Assessment Heart rate: 110 beats/min Blood pressure: 112/68 mm Hg Respiratory rate: 20 Red blood cell count: 5,000,000/mm3 White blood cell count: 10,000/mm3 Platelet count: 200,000/mm3 Left chest burn wound, 3 cm 2.5 cm 0.5 cm, wound bed pale, surrounding tissues with edema breaths/min Oxygen saturation: 94% Pain: 3/10 present Based on the documented data, which action should the nurse take next? a. Assess the clients skin for signs of adequate perfusion. b. Calculate intake and output ratio for the last 24 hours. c. Prepare to obtain blood and wound cultures. d. Place the client in an isolation room.

ANS: C Older clients have a decreased immune response, so they may not exhibit signs that their immune system is actively fighting an infection, such as fever or an increased white blood cell count. They also are at higher risk for sepsis arising from a localized wound infection. The burn wound shows signs of local infection, so the nurse should assess for this and for systemic infection before the client manifests sepsis. Placing the client in an isolation room, calculating intake and output, and assessing the clients skin should all be implemented but these actions do not take priority over determining whether the client has an infection.

17. A nurse teaches a client being treated for a full-thickness burn. Which statement should the nurse include in this clients discharge teaching? a. You should change the batteries in your smoke detector once a year. b. Join a program that assists burn clients to reintegration into the community. c. I will demonstrate how to change your wound dressing for you and your family. d. Let me tell you about the many options available to you for reconstructive surgery.

22. A nurse reviews the following data in the chart of a client with burn injuries: Admission Notes Wound Assessment 36-year-old female with Bilateral leg burns present bilateral leg burns NKDA Health history of asthma and seasonal allergies with a white and leatherlike appearance. No blisters or bleeding present. Client rates pain 2/10 on a scale of 0- 10. Based on the data provided, how should the nurse categorize this clients injuries? a. Partial-thickness deep b. Partial-thickness superficial c. Full thickness d. Superficial

ANS: C The characteristics of the clients wounds meet the criteria for a full-thickness injury: color that is black, brown, yellow, white, or red; no blisters; minimal pain; and firm and inelastic outer layer. Partial-thickness superficial burns appear pink to red and are painful. Partial-thickness deep burns are deep red to white and painful. Superficial burns are pink to red and are also painful.

11. A nurse reviews the laboratory results for a client who was burned 24 hours ago. Which laboratory result should the nurse report to the health care provider immediately? a. Arterial pH: 7.32 b. Hematocrit: 52% c. Serum potassium: 6.5 mEq/L d. Serum sodium: 131 mEq/L

8. A nurse prepares to administer intravenous cimetidine (Tagamet) to a client who has a new burn injury. The client asks, Why am I taking this medication? How should the nurse respond? a. Tagamet stimulates intestinal movement so you can eat more. b. It improves fluid retention, which helps prevent hypovolemic shock. c. It helps prevent stomach ulcers, which are common after burns. d. Tagamet protects the kidney from damage caused by dehydration.

ANS: C Ulcerative gastrointestinal disease (Curlings ulcer) may develop within 24 hours after a severe burn as a result of increased hydrochloric acid production and a decreased mucosal barrier. This process occurs because of the sympathetic nervous system stress response. Cimetidine is a histamine2 blocker and inhibits the production and release of hydrochloric acid. Cimetidine does not affect intestinal movement and does not prevent hypovolemic shock or kidney damage

A nurse assesses bilateral wheezes in a client with burn injuries inside the mouth. Four hours later the wheezing is no longer heard. Which action should the nurse take? a.Document the findings and reassess in 1 hour. b.Loosen any constrictive dressings on the chest. c.Raise the head of the bed to a semi-Fowler's position. d.Gather appropriate equipment and prepare for an emergency airway.

ANS: D Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose effective movement of air. When this occurs, wheezing is no longer heard, and neither are breath sounds. These clients can lose their airways very quickly, so prompt action is needed. The client requires establishment of an emergency airway. Swelling usually precludes intubation. The other options do not address this emergency situation.

The registered nurse assigns a client who has an open burn wound to a licensed practical nurse (LPN). Which instruction should the nurse provide to the LPN when assigning this client? a."Administer the prescribed tetanus toxoid vaccine." b."Assess the client's wounds for signs of infection." c."Encourage the client to breathe deeply every hour." d."Wash your hands on entering the client's room."

ANS: D Infection can occur when microorganisms from another person or from the environment are transferred to the client. Although all of the interventions listed can help reduce the risk for infection, handwashing is the most effective technique for preventing infection transmission

A nurse cares for a client who has burn injuries. The client's wife asks, "When will his high risk for infection decrease?" How should the nurse respond? a."When the antibiotic therapy is complete." b."As soon as his albumin levels return to normal." c."Once we complete the fluid resuscitation process." d."When all of his burn wounds have closed."

ANS: D Intact skin is a major barrier to infection and other disruptions in homeostasis. No matter how much time has passed since the burn injury, the client remains at high risk for infection as long as any area of skin is open. Although the other options are important goals in the client's recovery process, they are not as important as skin closure to decrease the client's risk for infection.

A nurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. Which action should the nurse take next? a.Administer furosemide (Lasix). b.Perform chest physiotherapy. c.Document and reassess in an hour. d.Place the client in an upright position.

ANS: D Pulmonary edema can result from fluid resuscitation given for burn treatment. This can occur even in a young healthy person. Placing the client in an upright position can relieve lung congestion immediately before other measures can be carried out. Although Lasix may be used to treat pulmonary edema in clients who are fluid overloaded, a client with a burn injury will lose a significant amount of fluid through the broken skin; therefore, Lasix would not be appropriate. Chest physiotherapy will not get rid of fluid.

18. A nurse assesses bilateral wheezes in a client with burn injuries inside the mouth. Four hours later the wheezing is no longer heard. Which action should the nurse take? a. Document the findings and reassess in 1 hour. b. Loosen any constrictive dressings on the chest. c. Raise the head of the bed to a semi-Fowlers position. d. Gather appropriate equipment and prepare for an emergency airway.

1. The registered nurse assigns a client who has an open burn wound to a licensed practical nurse (LPN). Which instruction should the nurse provide to the LPN when assigning this client? a. Administer the prescribed tetanus toxoid vaccine. b. Assess the clients wounds for signs of infection. c. Encourage the client to breathe deeply every hour. d. Wash your hands on entering the clients room.

13. A nurse cares for a client who has burn injuries. The clients wife asks, When will his high risk for infection decrease? How should the nurse respond? a. When the antibiotic therapy is complete. b. As soon as his albumin levels return to normal. c. Once we complete the fluid resuscitation process. d. When all of his burn wounds have closed.

ANS: D Intact skin is a major barrier to infection and other disruptions in homeostasis. No matter how much time has passed since the burn injury, the client remains at high risk for infection as long as any area of skin is open. Although the other options are important goals in the clients recovery process, they are not as important as skin closure to decrease the clients risk for infection.

12. A nurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. Which action should the nurse take next? a. Administer furosemide (Lasix). b. Perform chest physiotherapy. c. Document and reassess in an hour. d. Place the client in an upright position.

A client with a burn injury due to a house fire is admitted to the burn unit. The client's family asks the nurse why the client received a tetanus toxoid injection on admission. What is the nurse's best response to the client's family member? A. "The last tetanus injection was less than 5 years ago." B. "Burn wound conditions promote the growth of Clostridium tetani." C. "The wood in the fire had many nails, which penetrated the skin." D. "The injection was prescribed to prevent infection from Pseudomonas."

B. "Burn wound conditions promote the growth of Clostridium tetani Rationale A. Regardless of when the last tetanus injection is given, it is still given on admission to prevent Clostridium tetani. B. Burn wound conditions promote the growth of Clostridium tetani, and all burn clients are at risk for this dangerous infection. Tetanus toxoid, 0.5 mL given IM, enhances acquired immunity to C. tetani. This agent is routinely given when the client is admitted to the hospital. C. This is not the primaryreason the client received a tetanus toxoid injection D. Tetanus toxoid injection does not prevent Pseudomonas infection.

The nurse is caring for the client with burns to the face. Which statement by the client requires further evaluation by the nurse? A. "I am getting used to looking at myself." B. "I don't know what I will do when people stare at me." C. "I know that I will never look the way I used to, even after the scars heal." D. "My spouse does not stare at the scars as much as in the beginning."

B. "I don't know what I will do when people stare at me." Rationale A. This statement indicates that the client is coping effectively. B. This statement indicates that the client is not coping effectively; the nurse should assist the client in exploring coping techniques. C. This statement indicates that the client is coping effectively. D. This statement indicates that the client is coping effectively.

Which assessment does the nurse perform first on the client just admitted after an electrical injury with contact sites on the left hand and left foot? A. Core body temperature B. Electrocardiography C. Depth of burn injury D. Urine output

B. Electrocardiography

The nurse on a burn unit has just received change-of-shift report about these clients. Which client will the nurse assess first? A. Adult client admitted a week ago with deep partial-thickness burns over 35% of the body who is reporting pain B. Firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers, "I can't catch my breath!" C. An electrician who suffered external burn injuries a month ago and is asking the nurse to contact the health care provider immediately about discharge plans D. Older adult client admitted yesterday with partial- and full-thickness burns over 40% of the body who is receiving IV fluids at 250 mL/hr

B. Firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers, "I can't catch my breath!" Rationale A. This client is stable; although he is reporting pain, he does not require immediate assessment. B. Smoke inhalation and facial burns are associated with airway inflammation and obstruction. The client with difficulty breathing needs immediate assessment and intervention. C. This client is stable and has been in the burn unit for a month. The client's condition does not warrant that the nurse should assess this client first. D. This client is stable; he is receiving IV fluids and does not need to be assessed first.

The client is in the resuscitation phase of burn injury. Which route will the nurse use to administer pain medication to the client? A. Intramuscular B. Intravenous C. Sublingual D. Topical

B. Intravenous Rationale A. When administered to the client in the resuscitation phase of burn injury via the intramuscular route, drugs remain in the tissue spaces and do not relieve pain. In addition, when edema is present, all doses are rapidly absorbed at once when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics.

The client with burns to the head, neck, and upper body from a house fire starts drooling uncontrollably about 8 hours after the injury. What is the nurse's best first action? A. Ensure that the client remains NPO. B. Notify the Rapid Response Team. C. Slow the IV infusion rate. D. Raise the head of the bed.

B. Notify the Rapid Response Team. Rationale The client is at high risk for an inhalation injury from the circumstances of the burn (enclosed space and burns to the the head, neck, and upper body). The drooling indicates oral and throat swelling. This client is in danger of losing a patent airway and needs emergency intubation now.

The nursing student is caring for the client with open wound burns. Which nursing interventions will the nursing student provide for this client? Select all that apply. A. Provides cushions and rugs for comfort B. Performs frequent handwashing C. Places plants in the client's room D. Performs gloved dressing changes E. Uses disposable dishes

B. Performs frequent handwashing D. Performs gloved dressing changes E. Uses disposable dishes Rationale Cushions and rugs are difficult to clean and may harbor organisms.

Several clients have been brought to the emergency department (ED) after an office building fire. Which client is at greatest risk for inhalation injury? A. Middle-aged adult who is frantically explaining to the nurse what happened B. Young adult who suffered burn injuries in a closed space C. Adult with burns to the extremities D. Older adult with thick, tan-colored sputum

B. Young adult who suffered burn injuries in a closed space Rationale A. Clients typically have some type of respiratory distress. However, the client is talking without difficulty, which shows that the client has minimal respiratory distress. B. The client who suffered burn injuries in a closed space is at greatest risk for inhalation injury because the client breathed a greater concentration of confined smoke. C. Extensive burns to the hands and face, not the extremities, would be a greater risk. D. Sputum would be carbonaceous, not tan, if the client had suffered inhalation injury.

The nurse is caring for the client with burns. Which question will the nurse ask the client and family to assess their coping strategies? A. "Do you support each other?" B. "How do you plan to manage this situation?" C. "How have you handled similar situations before?" D. "Would you like to see a counselor?"

C. "How have you handled similar situations before?" Rationale A. Yes or no questions are not very effective in extrapolating helpful information. B. The client and family in this situation probably are overwhelmed and may not know how they will manage. This question does not assess coping strategies. C. This question assesses whether the client's and the family's coping strategies may be effective. D. Asking the client and the family if they would like to see a counselor does not assess their coping strategies.

The client who was the sole survivor in a house fire says, "I feel so guilty. Why did I survive?" What is the best response by the nurse? A. "Do you want to pray about it?" B. "I know, and you will have to learn to adapt to a new body image." C. "Tell me more." D. "There must be a reason."

C. "Tell me more." Rationale A. Offering to pray with the client assumes spirituality of the client and does not allow for grieving. The nurse should never assume that the client is religious. B. This response only serves to add stress to the client's situation. C. This response encourages therapeutic grieving. D. This response minimizes the grieving process by not allowing the client to express her or his concerns.

Which strategies will the nurse include when teaching the college student about fire prevention in the dormitory room? A. Use space heaters to reduce electrical costs. B. Check water temperature before bathing. C. Do not smoke in bed. D. Wear sunscreen.

C. Do not smoke in bed. Rationale A. Use of space heaters may increase the risk for fire, especially if they are knocked over and left unattended. B. Checking water temperature does not prevent fires, but it should be checked if the client has reduced sensation in the hands or feet. C. Smoking in bed increases the risk for fire because the person could fall asleep. D. Sunscreen is advised to prevent sunburn.

The client with burn injuries is being admitted. Which priority does the nurse anticipate within the first 24 hours? A. Body temperature assessment B. Emotional support C. Fluid resuscitation D. Sterile dressing changes

C. Fluid resuscitation Rationale A. Assessment of body temperature is not the priority for this client. B. Although emotional support is important, this is not the priority during the resuscitation phase for this client. C. The client will require fluid resuscitation because fluid does not stay in the vessels after a burn injury. D. Although sterile dressing changes are important, this is not the priority for this client.

In assessing the client in the rehabilitative phase of burn therapy, which priority problem does the nurse anticipate? A. Acute Pain B. Potential for inadequate oxygenation C. Reduced self-image D. Potential for infection

C. Reduced self-image Rationale A. Acute Pain is relevant in the resuscitation phase of burn injury. B. Potential for inadequate oxygenation is relevant in the resuscitation phase of burn injury. C. In the rehabilitative phase of burn therapy, the client is discharged and his or her life is not the same. A priority problem of reduced self-image is expected. D. Potential for infection is relevant in the acute phase of burn injury.

Which clinical manifestation is indicative of wound healing for the client in the acute phase of burn injury? A. Pale, boggy, dry, or crusted granulation tissue B. Increasing wound drainage C. Scar tissue formation D. Sloughing of grafts

C. Scar tissue formation Rationale A. Pale, boggy, dry, or crusted granulation tissue is indicative of infection. B. Increasing wound drainage is indicative of infection. C. Indicators of wound healing include the presence of granulation, re-epithelization, and scar tissue formation. D. Sloughing of grafts is indicative of infection.

The nurse is caring for a burn client who is receiving topical gentamicin sulfate (Garamycin). What laboratory value will the nurse plan to monitor? A. Blood glucose B. C-reactive protein C. Serum and urine creatinine D. Platelet count

C. Serum and urine creatinine Rationale A. 2 Topical gentamicin sulfate does not affect blood sugar. B. C-reactive protein is used as a marker of inflammation. C. Topical gentamicin may have nephrotoxic effects, and the nurse should monitor serum and urine creatinine clearance before and during treatment. D. Topical gentamicin sulfate does not alter platelet counts.

Which assessment will the nurse prioritize for the client in the acute phase of burn injury? A. Bowel sounds B. Muscle strength C. Signs of infection D. Urine output

C. Signs of infection Rationale A. Assessing bowel sounds is not the priority during the acute phase of burn injury. B. Assessing muscle strength is not the priority during the acute phase of burn injury. C. The client with burn injury is at risk for infection as a result of open wounds and reduced immune function. Burn wound sepsis is a serious complication of burn injury, and nfection is the leading cause of death during the acute phase of recovery. D. Assessing urine output is not the priority during the acute phase of burn injury.

A burned client newly arrived from an accident scene is prescribed 4 mg of morphine sulfate intravenously. What is the most important reason the nurse administers the analgesic to this client by the intravenous (IV) route? A. The drug will be effective more quickly than if given IM or subcutaneously. 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 has delayed gastric emptying.

C. The danger of an overdose during fluid remobilization is reduced. Rationale Although providing some pain relief is a high priority and giving the drug by the IV route instead of the IM, subcutaneous, or oral routes does increase the rate of effect, the most important reason is to prevent an overdose from the accumulation of drug in the interstitial space during the fluid shift of the emergent phase. When edema is present, cumulative doses are rapidly absorbed while the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics

Which assessment information about a 60-kg client admitted 12 hours ago with a full-thickness burn over 30% of the total body surface area will be of greatest concern to the nurse? A. Bowel sounds are absent. B. The pulse oximetry level is 91%. C. The serum potassium level is 8.1 mEq/L. D. Urine output since admission is 370 mL.

C. The serum potassium level is 8.1 mEq/L. Rationale A. Absence of bowel sounds is a normal finding for the client during the resuscitation phase of burn injury. B. A pulse oximetry level of 91% is a normal finding for the client during the resuscitation phase of burn injury. C. An elevated serum potassium level can cause cardiac arrest. D. Urine output of 370 mL since admission is normal during the resuscitation phase of burn injury.

The nurse is evaluating the effectiveness of fluid resuscitation for the client in the resuscitation phase of burn injury. Which finding does the nurse correlate with clinical improvement? A. Blood urea nitrogen (BUN), 36 mg/dL B. Creatinine, 2.8 mg/dL C. Urine output, 40 mL/hr D. Urine specific gravity, 1.042

C. Urine output, 40 mL/hr Rationale A. A BUN of 36 mg/dL is above normal. B. A creatinine of 2.8 mg/dL is above normal. C. Fluid resuscitation is provided at the rate needed to maintain urine output at 30 to 50 mL or 0.5 mL/kg/hr. D. A urine specific gravity of 1.042 is above normal.

When delegating care for clients on the burn unit, which client does the charge nurse assign to an RN who has floated to the burn unit from the intensive care unit (ICU)? Burn unit client who is being discharged after 6 weeks and needs teaching about wound care Recently admitted client with a high-voltage electrical burn A client who has a 25% total body surface area (TBSA) burn injury, for whom daily wound débridement has been prescribed Client receiving IV lactated Ringer's solution at 150 mL/hr

Client receiving IV lactated Ringer's solution at 150 mL/hr An RN float nurse from ICU will be familiar with administration of IV fluids and with signs of fluid overload, such as shortness of breath, and so could be assigned to the client receiving IV lactated Ringer's solution at 150 mL/hr.The client needing teaching about wound care, the client with a high-voltage electrical burn, and the client with a 25% TBSA burn injury all require specialized knowledge about burn injuries and should be assigned to RNs who have experience caring for clients with burn injuries

When delegating care for clients on the burn unit, which client will the charge nurse assign to an RN who has floated to the burn unit from the pediatric unit? A. Burn unit client who is being discharged after 6 weeks and needs teaching about wound care B. Recently admitted client with a high-voltage electrical burn C. A client who has a 25% total body surface area (TBSA) burn injury, for whom daily wound débridement has been prescribed D. Client receiving IV lactated Ringer's solution at 100 mL/hr

D. Client receiving IV lactated Ringer's solution at 100 mL/hr Rationale A. This client requires specialized knowledge about burn injuries and should be assigned to RNs who have experience caring for clients with burn injuries. B. This client requires specialized knowledge about assessment and interventions in burn injuries and should be assigned to RNs who have experience caring for clients with burn injuries. C. This client requires specialized knowledge about interventions in burn injuries and should be assigned to RNs who have experience caring for clients with burn injuries. D. An RN float nurse will be familiar with administration of IV fluids and with signs of fluid overload, such as shortness of breath.

The client is in the acute phase of burn injury. In which situation will the nurse decide to coordinate with the dietitian? A. Discouraging having food brought in from the client's favorite restaurant B. Providing more palatable choices for the client C. Helping the client lose weight D. Planning additions to the standard nutritional pattern

D. Planning additions to the standard nutritional pattern Rationale A. It is fine for the client with a burn injury to have food brought in from the outside. B. The hospital kitchen can be consulted to see what other food options may be available to the client. C. It is not therapeutic for the client with burn injury to lose weight. D. Nutritional requirements for the client with a large burn area can exceed 5000 kcal/day. In addition to a high calorie intake, the burn client requires a diet high in protein for wound healing. Consultation with the dietitian is required to help the client achieve the correct nutritional balance.

The nurse assesses the wound of a client burned as a result of stepping into a bathtub filled with very hot water. Which assessment finding of the burned areas on the tops of both feet does the nurse use as a basis to document a probable full-thickness injury? A. Most of the wounded area is red. B. The client reports that the area hurts when touched. C. The area does not blanch when firm pressure is applied. D. Thrombosed blood vessels are visible beneath the skin surface.

D. Thrombosed blood vessels are visible beneath the skin surface. Rationale A. Red areas can be associated with nearly any depth of burn injury. B. The presence of pain is not a good indicator of burn depth. Although full-thickness injuries have much less pain than partial-thickness injuries, pain may still be present. C. Deep partial-thickness injuries may or may not blanch with firm pressure. D. The presence of thrombosed blood vessels beneath the skin surface is a strong indication of a full-thickness injury. Partial-thickness injuries can directly damage more superficial blood vessels but do not cause thrombosis of deeper vessels.

Which of the following provides clues about fluid volume status? Select all that apply.

Daily weights Hourly urine output pg. 1827

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 pg. 1808

The nurse on a burn unit has just received change-of-shift report about these clients. Which client does the nurse assess first? Adult client admitted a week ago with deep partial-thickness burns over 35% of the body who is reporting pain Firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers, "I can't catch my breath!" An electrician who suffered external burn injuries a month ago and is asking the nurse to contact the health care provider immediately about discharge plans Older adult client admitted yesterday with partial- and full-thickness burns over 40% of the body who is receiving IV fluids at 250 mL/hr

Firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers, "I can't catch my breath!" The nurse first needs to assess the firefighter recently admitted with smoke inhalation. Smoke inhalation and facial burns are associated with airway inflammation and obstruction. The client with difficulty breathing needs immediate assessment and intervention.Although the client admitted a week ago with deep partial-thickness burns is reporting pain, this client does not require immediate assessment. The electrician who suffered burn injuries a month ago is stable and has been in the burn unit for a month, so the client's condition does not warrant that the nurse should assess this client first. The older adult client admitted yesterday with burns over 40% of the body is stable; he is receiving IV fluids and does not need to be assessed first.

The nurse is reviewing the health history for an older adult client recently admitted to the burn unit with severe burns to the upper body from a house fire. The nurse plans to contact the health care provider if the client's history reveals which condition? Heart failure Diverticulitis Hypertension Emphysema

Heart failure The nurse will contact the health care provider if the client's history reveals specific information about cardiac or kidney problems, chronic alcoholism, substance abuse, or diabetes mellitus. Any of these problems can influence fluid resuscitation. A client's health history, including any preexisting illnesses, must be known for appropriate management. The stress of a burn injury can make a mild disease process worsen. In older clients, especially those with cardiac disease, a complicating factor in fluid resuscitation may be heart failure or myocardial infarction.Diverticulitis, hypertension, and emphysema are important to be aware of in guiding treatment options. However, heart failure is the main concern when attempting to optimize this older client's fluid resuscitation.

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately?

Hoarseness of the voice pg. 1812

In assessing a client in the rehabilitative phase of burn therapy, which priority problem does the nurse anticipate? Intense pain Potential for inadequate oxygenation Impaired self-image Potential for infection

Impaired self-image A priority problem of impaired self-image is expected during the rehabilitation phase. During this phase, the client is discharged and his or her life is not the same.A priority problem of impaired self-image is expected. Intense pain and potential for inadequate oxygenation are relevant in the resuscitation phase of burn injury. Potential for infection is relevant in the acute phase of burn injury.

To position a client's burned upper extremities appropriately, how does the nurse position the client's elbow? In a neutral position In a position of comfort Slightly flexed Slightly hyperextended

In a neutral position The neutral (extended) position is the correct placement of the elbow to prevent contracture development.Placing the elbow in a position of comfort is not the best placement because the client then usually wants to flex the joint, which increases the risk for contracture development. The slightly flexed position increases the risk for contracture development. The slightly hyperextended position is not indicated and can be painful.

A client is in the resuscitation phase of burn injury. Which route does the nurse use to administer pain medication to the client? Intramuscular Intravenous Sublingual Topical

Intravenous During the resuscitation phase, the intravenous (IV) route is used for giving opioid drugs because of problems with absorption from the muscle and stomach.When these agents (opioid drugs) are given by the intramuscular or subcutaneous route, they remain in the tissue spaces and do not relieve pain. In addition, when edema is present, all doses are rapidly absorbed at once when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics. The sublingual route may not be effective, and because the skin is too damaged, the topical route is not indicated for administering drugs to the client in the resuscitation phase of burn injury.

Which of the following is the effect of protein catabolism in a client with severe burns?

It compromises wound healing and immunocompetence. pg. 1806

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. pg. 1826

Which wound assessment characteristics suggest a superficial partial-thickness burn injury? Black-brown coloration Painful blisters Moderate to severe edema Absence of blisters

Painful blisters Characteristics of a superficial partial-thickness burn injury include pink to red coloration, mild to moderate edema, pain, and blisters.A black-brown coloration is more suggestive of full-thickness burn injury. Moderate to severe edema and absence of blisters may be present with deep partial-thickness to full-thickness burn injuries.

A nursing student is caring for a client with open-wound burns. Which nursing interventions does the nursing student provide for this client? Select all that apply. Provides cushions for comfort Performs frequent handwashing Places plants in the client's room Performs gloved dressing changes Uses disposable dishes

Performs frequent handwashing Performs gloved dressing changes Uses disposable dishes Frequent handwashing is the most effective technique for preventing infection. Gloves should be worn when changing dressings to reduce the risk for infection. Equipment is not shared with other clients to prevent the risk for infection. Disposable items (e.g., pillows, dishes) are used as much as possible.Cushions are difficult to clean and may harbor organisms, and so are not provided. To avoid exposure to Pseudomonas, having plants or flowers in the room is prohibited.

A client is in the acute phase of burn injury. For which action does the nurse decide to coordinate with the registered dietitian? Discouraging having food brought in from the client's favorite restaurant Providing more palatable choices for the client Helping the client maintain a desirable weight Planning additions to the standard nutritional pattern

Planning additions to the standard nutritional pattern Consultation with the dietitian is required to help the client achieve the correct nutritional balance. Nutritional requirements for the client with a large burn area can exceed 5000 kcal/day. In addition to a high calorie intake, the burn client requires a diet high in protein for wound healing.It is fine for the client with a burn injury to have food brought in from the outside. The hospital kitchen can be consulted to see what other food options may be available to the client. It is not therapeutic for the client with burn injury to lose weight.

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

Pulmonary system pg. 1814

A newly admitted client has deep partial-thickness burns. The nurse expects to see which clinical manifestations? Red and white wounds with mild pain to palpation Painless, brownish yellow eschar Painful reddened blisters Black skin with eschar and no pain

Red and white wounds with mild pain to palpation A red and white wound bed characterizes deep partial-thickness burns. Blisters are rare. Pain is less than with other types of burns because nerve endings are affected.Painless, brownish yellow eschar characterizes a full-thickness burn. A painful reddened blister is seen with a superficial partial-thickness burn. Painless black skin with eschar is seen in a deep full-thickness burn.

The nurse is caring for a client with a burn injury who is receiving silver sulfadiazine (Silvadene) to the burn wounds. Which best describes the goal of topical antimicrobials? Reduction of bacterial growth in the wound and prevention of systemic sepsis Prevention of cross-contamination from other clients in the unit Enhanced cell growth Reduced need for a skin graft

Reduction of bacterial growth in the wound and prevention of systemic sepsis The best description of the goal of topical antimicrobials such as silver sulfadiazine is that they help prevent infection in burn wounds.Topical antimicrobials such as silver sulfadiazine do not prevent cross-contamination from other clients in the unit. They do not enhance cell growth, nor do they minimize the need the need for a skin graft.

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 pg. 1811

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. pg. 1815

Which clinical manifestation is indicative of wound healing for a client in the acute phase of burn injury? Pale, boggy, dry, or crusted granulation tissue Increasing wound drainage Scar tissue formation Sloughing of grafts

Scar tissue formation Indicators of wound healing include the presence of granulation, reepithelialization, and scar tissue formation.Pale, boggy, dry, or crusted granulation tissue is indicative of infection, as are increasing wound drainage and sloughing of grafts.

Which assessment is the nurse's highest priority in caring for a client in the acute phase of burn injury? Bowel sounds Muscle strength Signs of infection Urine output

Signs of infection The client with burn injury is at highest risk for infection as a result of open wounds and reduced immune function. Burn wound sepsis is a serious complication of burn injury, and infection is the leading cause of death during the acute phase of recovery.Assessing bowel sounds, assessing muscle strength, and assessing urine output are important but not the priority during the acute phase of burn injury.

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. pg. 1807

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. pg. 1825

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 0.3 to 0.5 mL/kg/hour. pg. 1811

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. pg. 1809

Which of the following is true regarding a split-thickness skin graft?

The epidermis and a thin layer of dermis are harvested from the client's skin.

Which assessment information about a 60-kg client admitted 12 hours ago with a full-thickness burn over 30% of the total body surface area is of greatest concern to the nurse? Bowel sounds are absent. The pulse oximetry level is 91%. The serum potassium level is 6.1 mEq/L (6.1 mmol/L). Urine output since admission is 370 mL.

The serum potassium level is 6.1 mEq/L (6.1 mmol/L). The greatest concern for the nurse is to notice an elevated serum potassium level that can cause cardiac dysrhythmias and arrest.Absence of bowel sounds, a pulse oximetry level of 91%, and urine output of 370 mL since admission are normal findings during the resuscitation phase of burn injury.

The client is a burn victim who is noted to have increasing edema and decreased urine output as a result of the inflammatory compensation response. What does the nurse do first? Administer a diuretic. Provide a fluid bolus. Recalculate fluid replacement based on time of hospital arrival. Titrate fluid replacement.

Titrate fluid replacement. The nurse first needs to adjust and titrate the intravenous fluid rate on the basis of urine output plus serum electrolyte values.A common mistake in treatment is giving diuretics to increase urine output. Giving a diuretic will actually decrease circulating volume and cardiac output by pulling fluid from the circulating blood volume to enhance diuresis. Fluid boluses are avoided because they increase capillary pressure and worsen edema. Fluid replacement formulas are calculated from the time of injury, not from the time of arrival at the hospital.

What is an early sign of sepsis in the burn injured client?

Widened pulse pressure pg. 1829

Several clients have been brought to the emergency department after an office building fire. Which client is at greatest risk for inhalation injury? Middle-aged adult who is frantically explaining to the nurse what happened Young adult who suffered burn injuries in a closed space Adult with burns to the extremities Older adult with thick, tan-colored sputum

Young adult who suffered burn injuries in a closed space The client who suffered burn injuries in a closed space is at greatest risk for inhalation injury because the client breathed a greater concentration of confined smoke.Clients who experienced a fire typically have some type of respiratory distress. However, the client talking without difficulty demonstrates minimal respiratory distress. Extensive burns to the hands and face, not the extremities, would be a greater risk. Sputum would be carbonaceous, not tan, if the client had suffered inhalation injury.

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. pg. 1806

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. pg. 1826

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 charred. What depth of burn injury does the client have?

BURNS

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