Burns exam 3
A client is on nothing by mouth (NPO) status and has a nasogastric (NG) tube in place after suffering bilateral burns to the legs. The nurse determines that the client's gastrointestinal (GI) status is least satisfactory if which finding is noted on assessment? 1. Gastric pH of 3 2. Absence of abdominal discomfort 3. GI drainage that is guaiac negative 4. Presence of hypoactive bowel sounds
1. Gastric pH of 3 Rationale: The gastric pH should be maintained at 7 or greater with the use of prescribed antacids and histamine 2 (H2) receptor-blocking agents. Lowered pH (to the acidic range) in the absence of food or tube feedings can lead to erosion of the gastric lining and ulcer development. Absence of discomfort and bleeding (guaiac-negative drainage) are normal findings. The client's bowel sounds may be expected to be hypoactive in the absence of oral or NG tube intake.
The nurse is developing a nursing care plan for a client with a circumferential burn injury of the extremity. The client problem states ineffective tissue perfusion. Which nursing intervention should the nurse include in the plan of care for the client? 1. Monitor peripheral pulses every hour. 2. Keep the extremities in a dependent position. 3. Document any changes that occur in the pulse. 4. Place pressure dressings and wraps around the burn sites.
1. Monitor peripheral pulses every hour. Rationale: In a client with ineffective tissue perfusion related to a circumferential burn injury, peripheral pulses should be assessed every hour for 72 hours. The affected extremities should be elevated, and the health care provider should be notified of any changes in pulses, capillary refill, or pain sensation. Pressure dressings and wraps should not be applied around the circumferential burn because they could cause a further alteration in peripheral circulation
The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy? 1. Return of distal pulses 2. Brisk bleeding from the site 3. Decreasing edema formation 4. Formation of granulation tissue
1. Return of distal pulses Rationale: Escharotomies are performed to relieve the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential third-degree burn. Escharotomies are performed through avascular eschar to subcutaneous fat. Although bleeding may occur from the site, it is considered a complication rather than an anticipated therapeutic outcome. Usually, direct pressure with a bulky dressing and elevation control the bleeding, but occasionally an artery is damaged and may require ligation. Escharotomy does not affect the formation of edema. Formation of granulation tissue is not the intent of an escharotomy.
A client who suffered carbon monoxide poisoning from working on an automobile in a closed garage has a carbon monoxide level of 15%. The nurse should anticipate observing which sign/symptom? 1. Coma 2. Flushing 3. Dizziness 4. Tachycardia
2. Flushing Rationale: The signs and symptoms worsen as the carbon monoxide level rises in the bloodstream. Impaired visual acuity occurs at 5% to 10%, whereas flushing and headache are seen at 11% to 20%. Nausea and impaired dexterity appear at levels of 21% to 30%, and a 31% to 40% level is accompanied by vomiting, dizziness, and syncope. Levels of 41% to 50% cause tachypnea and tachycardia, and those higher than 50% result in coma and death. IGGY page 522
A client is admitted to the hospital emergency department after receiving a burn injury in a house fire. The skin on the client's trunk is tan, dry, and hard. It is edematous but not very painful. The nurse determines that this client's burn should be classified as which type? 1. Superficial 2. Full-thickness 3. Deep partial-thickness 4. Partial-thickness superficial
2. Full-thickness Rationale: Full-thickness burns involve the epidermis, the full dermis, and some of the subcutaneous fat layer. The burn appears to be a tan or fawn color, with skin that is hard, dry, and inelastic. Edema is severe, and the accumulated fluid compresses tissue underneath because of eschar formation. Some nerve endings have been damaged, and the area may be insensitive to touch, with little or no pain.
The nurse has developed a nursing care plan for a client with a burn injury. The client problem states deficient fluid volume. Which intervention should the nurse include in the plan of care as a priority intervention? 1. Monitor vital signs every 4 hours. 2. Monitor mental status every hour. 3. Monitor intake and output every shift. 4. Obtain and record weight every other day.
2. Monitor mental status every hour. Rationale: In a client with deficient fluid volume secondary to a burn injury, vital signs should be monitored every hour (every 4 hours is too infrequent) until the client is hemodynamically stable. The nurse should monitor the mental status of the client every hour for the first 48 hours. The weight should be obtained and recorded daily or twice daily, and intake and output measurements should be recorded on an hourly basis.
An adult client trapped in a burning house has suffered burns to the back of the head, upper half of the posterior trunk, and the back of both arms. Using the rule of nines, what does the nurse determine the extent of the burn injury to be? Fill in the blank.
22.5% Rationale: According to the rule of nines, the posterior side of the head equals 4.5%, the back of both arms equals 9%, and the upper half of the posterior trunk equals 9%, totaling 22.5%.
A client sustained a burn from cutaneous exposure to lye. At the site of injury, copious irrigation to the site was performed for 1 hour. On admission to the hospital emergency department, the nurse assesses the burn site. Which findings would indicate that the chemical burn process is continuing? 1. Eschar 2. Intact blisters 3. Liquefaction necrosis 4. Cherry-red, firm tissue
3. Liquefaction necrosis Rationale: Alkalis, such as lye, cause a liquefaction necrosis, and exposure to fat results in formation of a soapy coagulum. Thick, leathery eschar forms with exposure to acids or heat. Intact blisters indicate a partial-thickness thermal injury. Cherry-red, firm tissue can occur as a result of thermal injury. IGGY page 518
A client has undergone fasciotomy to treat compartment syndrome of the leg. The nurse should anticipate that which type of wound care to the fasciotomy site will be prescribed? 1. Dry sterile dressings 2. Hydrocolloid dressings 3. Moist sterile saline dressings 4. One-half strength povidone-iodine (Betadine) dressings
3. Moist sterile saline dressings Rationale: The fasciotomy site is not sutured but is left open to relieve pressure and edema. The site is covered with moist sterile saline dressings. After 3 to 5 days, when perfusion is adequate and edema subsides, the wound is débrided and closed. Because this is an open wound, dry dressings should not be used. A hydrocolloid dressing is not indicated for use with clean, open incisions. The incision is clean, not dirty, so povidone-iodine should not be required. Also, this agent is irritating to tissues. IGGY page 1157
Collagenase (Santyl) is prescribed for a client with a severe burn to the hand. The home care nurse provides instructions to the client regarding the use of the medication. Which client statement indicates an accurate understanding of the use of this medication? 1. "I will apply the ointment at bedtime and in the morning." 2. "I will apply the ointment once a day and leave it open to the air." 3. "I will apply the ointment twice a day and leave it open to the air." 4. "I will apply the ointment once a day and cover it with a sterile dressing."
4. "I will apply the ointment once a day and cover it with a sterile dressing." Rationale: Santyl is used to promote debridement of dermal lesions and severe burns. It is applied once daily and covered with a sterile dressing. IGGY page 534
The nurse is supervising a nursing student who is delivering care to a client with a burn injury to the chest. Nitrofurazone is prescribed to be applied to the site of injury. The nurse should intervene if the student planned to implement which action to apply the medication? 1. Wash the burn site. 2. Apply 1/16-inch film directly to the burn sites. 3. Apply the medication with a sterile gloved hand. 4. Apply saline-soaked dressings over the medication.
4. Apply saline-soaked dressings over the medication. Rationale: Nitrofurazone is applied topically to the burn and has a broad spectrum of antibiotic activity. It is used in second- or third-degree burns when bacterial resistance to other agents is a potential problem. The burn site is washed before medication application. A film of 1/16 inch is applied directly to the burn using a sterile gloved hand. Saline-soaked dressings are not used with this medication because they will inactivate the medication's effect. In addition, wet dressings present the risk for infection, and infection is a primary concern with a client who is burned. IGGY page 534
The nurse is caring for a client who was admitted to the burn unit after sustaining a burn injury covering 30% of the body. What is the most appropriate time frame for the emergent phase? 1. The entire period of time during which rehabilitation occurs 2. The period from the time the client is stable until all burns are covered with skin 3. The period from the time the burn was incurred to the time when the client is admitted to the hospital 4. The period from the time the burn was incurred to the time when the client is considered physiologically stable
4. The period from the time the burn was incurred to the time when the client is considered physiologically stable Rationale: The emergent phase of burn care generally extends from the time the burn injury is incurred until the time when the client is considered physiologically stable. The acute phase lasts until all full-thickness burns are covered with skin. The rehabilitation period lasts approximately 5 years for an adult and includes reintegration into society. IGGY page 513
32. The nurse assesses a client in the burn unit after the client was repositioned by the nursing assistant. The nurse intervenes after finding the client repositioned in what manner? a. Supine with one pillow behind the head b. Semi-Fowler's position with arms elevated c. Wrists extended to 30 degrees in a splint d. A towel roll placed under the neck or shoulder
ANS: A Clients must be positioned to prevent contractures. The function that would be disrupted by a contracture to the posterior neck is flexion. The client should not be positioned with a pillow behind the head; this would increase flexion. The nurse must intervene and position the client so that neck flexion does not occur. The other options include proper positioning techniques that will help prevent contracture.
33. A client has severe burns around the right hip. Which position does the nurse instruct the nursing assistant to use to maintain maximum function of this joint? a. Hip maintained in 30-degree flexion b. Hip at zero flexion with leg flat c. Knee flexed at 30-degree angle d. Leg abducted with foam wedge
ANS: B Maximum function for ambulation occurs when the hip and the leg are maintained at full extension with neutral rotation. Although the client does not have to spend 24 hours in this position, he or she should be in this position (in bed or standing) longer than with the hip in any degree of flexion
16. A client who is receiving fluid resuscitation per the Parkland formula after a serious burn continues to have urine output ranging from 0.2 to 0.25 mL/kg/hour. After the health care provider checks the client, which order does the nurse question? a. Increase IV 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 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. The other orders are appropriate.
34. A client who suffered burns in a house fire reports a headache and is not consistently oriented to time. Which intervention by the nurse is most appropriate? 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 Status 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.
13. A client with a new burn injury asks the nurse why he is receiving intravenous cimetidine (Tagamet). What is the nurse's best response? a."Tagamet will stimulate intestinal movement so you can eat more." b. "Tagamet can help prevent hypovolemic shock, which can be fatal." c. "This will help prevent stomach ulcers, which are common after burns." d. "This drug will help prevent kidney 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 inhibits the production and release of hydrochloric acid. Cimetidine does not affect intestinal movement and does not prevent hypovolemic shock or kidney damage.
25. The nurse provides wound care for a client 48 hours after a burn injury. To achieve the desired outcome of the procedure, which action does the nurse perform first? a. Apply silver sulfadiazine (Silvadene) ointment. b. Cover the area with an elastic wrap. c. Place a synthetic dressing over the area. d. Remove loose nonviable tissue.
ANS: D All steps are part of the nonsurgical wound care for clients with burn injuries. The first step in this process consists of removing exudates and necrotic tissue. This promotes wound healing.
19. A client who was burned has crackles in both lung bases and a respiratory rate of 40 breaths/min and is coughing up blood-tinged sputum. Which action by the nurse takes priority? a. Administer digoxin. 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. Digoxin may be given later to enhance cardiac contractility to prevent backup of fluid into the lungs. Chest physiotherapy will not get rid of fluid.
