Burns

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? The entire period of time during which rehabilitation occurs The period from the time the client is stable to the time when all burns are covered with skin The period from the time the burn was incurred to the time when the client is admitted to the hospital The period from the time the burn was incurred to the time when the client is considered physiologically stable

The period from the time the burn was incurred to the time when the client is considered physiologically stable

A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem? Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg White pulmonary secretions Urine output of 20 ml/hour Rectal temperature of 100.4° F (38° C)

Urine output of 20 ml/hour

Prepu Determining the depth of a burn is difficult initially because there are combinations of injury zones in the same location. The area of intermediate burn injury is the zone in which blood vessels are damaged, but tissue has the potential to survive. This is called the zone of: hyperemia. coagulation. stasis. hypotension.

stasis.

prepu A nurse is caring for a client with skin grafts covering full-thickness burns on the arms and legs. During dressing changes, the nurse should: wrap elastic bandages on the arms and legs, proximally to distally, to promote venous return. apply maximum bandages to allow for absorption of drainage. remove bandages with clean gloves. wrap elastic bandages distally to proximally on dependent areas

wrap elastic bandages distally to proximally on dependent areas.

Collagenase 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? "I will apply the ointment at bedtime and in the morning." "I will apply the ointment once a day and leave it open to the air." "I will apply the ointment twice a day and leave it open to the air." "I will apply the ointment once a day and cover it with a sterile dressing."

"I will apply the ointment once a day and cover it with a sterile dressing."

A client is cared for in a burn unit after suffering partial-thickness burns. The client's laboratory work reveals a positive wound culture for gram-negative bacteria. The health care provider orders silver sulfadiazine to be applied to the client's burns. The nurse provides information to the client about the medication. Which statement made by the client indicates an understanding about this treatment? Select all that apply. "This medication will stain my skin permanently." "This medication will help my burn heal." "This medication will be applied directly to the wound." "This medication is an antibacterial."

"This medication will help my burn heal." "This medication will be applied directly to the wound." "This medication is an antibacterial."

A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the client? 100% oxygen via an aerosol mask Oxygen via nasal cannula at 6 L/minute Oxygen via nasal cannula at 15 L/minute 100% oxygen via a tight-fitting, nonrebreather face mask

100% oxygen via a tight-fitting, nonrebreather face mask

A client sustains a burn injury to the entire right and left arms, the right leg, and the anterior thorax. According to the rule of nines, the nurse would assess that this injury constitutes which body percentage? Fill in the blank.

54

A 60-kg client has sustained third-degree burns over 40% of the body. Using the Parkland (Baxter) formula, the minimum fluid requirements are which during the first 24 hours after the burn? 9600 mL of lactated Ringer's solution 4800 mL of 0.9% normal saline solution 2400 mL of 0.45% normal saline solution 1200 mL of 5% dextrose in water solution

9600 mL of lactated Ringer's solution

ATI A nurse is assessing a client who sustained superficial partial-thickness and deep partial-thickness burns 72 hr ago. Which of the following findings should the nurse report to the provider? A. Edema in the burned extremities B. Severe pain at the burn sites C. Urine output of 30 mL/hr D. Temperature of 39.1°C (102.4°F)

A. Edema in the burned extremities indicates infection

A client is brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply. Restrict fluids. Assess for airway patency. Administer oxygen as prescribed. Place a cooling blanket on the client. Elevate extremities if no fractures are present. Prepare to give oral pain medication as prescribed.

Assess for airway patency. Administer oxygen as prescribed. Assess for airway patency. Administer oxygen as prescribed. The primary goal for a burn injury is to maintain a patent airway, administer intravenous (IV) fluids to prevent hypovolemic shock, and preserve vital organ functioning. Therefore, the priority actions are to assess for airway patency and maintain a patent airway. The nurse then prepares to administer oxygen. Oxygen is necessary to perfuse vital tissues and organs. An IV line should be obtained and fluid resuscitation started. The extremities are elevated to assist in preventing shock and decrease fluid moving to the extremities, especially in the burn-injured upper extremities. The client is kept warm, because the loss of skin integrity causes heat loss. The client is placed on NPO (nothing by mouth) status because of the altered gastrointestinal function that occurs as a result of a burn injury.

The nurse is performing an assessment on a client who sustained circumferential burns of both legs. Which assessment would be the initial priority in caring for this client? Assessing heart rate Assessing respiratory rate Assessing peripheral pulses Assessing blood pressure (BP)

Assessing peripheral pulses

The emergency department nurse is caring for a client who has sustained chemical burns to the esophagus after ingestion of lye. The nurse reviews the primary health care provider's prescriptions and should plan to question which prescription? Gastric lavage Intravenous (IV) fluid therapy Nothing by mouth (NPO) status Preparation for laboratory studies

Gastric lavage

What are the expected findings in the fluid remobilization phase (acute phase, diuresis) that the nurse should monitor for? Select all that apply. Hemodilution Increased urinary output Sodium deficit Hypoglycemia Metabolic alkalosis

Hemodilution Increased urinary output Sodium deficit

The nurse is caring for a client with full-thickness circumferential burns of the entire trunk of the body who is on a mechanical ventilator. Which finding suggests that an escharotomy may be necessary? Pallor of all extremities Pulse oximetry reading of 93% Peripheral pulses are diminished High pressure alarm keeps sounding on the ventilator

High pressure alarm keeps sounding on the ventilator

The nurse is caring for a patient who sustained a full-thickness burn to his arm when he was scalded with boiling water. How did the nurse determine that the patient's burns are full-thickness burns? Classification by the appearance of blisters Usually very painful because of exposed nerve endings Not associated with edema formation Identification by the destruction of the dermis and epidermis

Identification by the destruction of the dermis and epidermis

A client who is being evaluated for thermal burn injuries to the arms and legs complains of thirst and asks the nurse for a drink. Which action by the nurse is most appropriate? Allow the client to have full liquids. Give the client small glasses of clear liquids. Order the client a full meal tray with extra liquids. Keep the client on NPO (nothing by mouth) status.

Keep the client on NPO (nothing by mouth) status. The client should be maintained on NPO status because burn injuries frequently result in paralytic ileus. The client also should be told that fluids could cause vomiting because of the effect of the burn injury on gastrointestinal tract functioning.

Which of the following is the preferred IV fluid for burn resuscitation? D5W Normal saline (NS) Lactated Ringer's (LR) Total parenteral nutrition (TPN)

Lactated Ringer's (LR)

prepu Which of the following is the analgesic of choice for burn pain? Demerol Morphine sulfate Tylenol with codeine Fentanyl

Morphine sulfate

During the recovery of an extensive burn, the client is uncomfortable wearing the tight-fitting custom garment. Which is the best response by the nurse? "The garment acts as a skin layer and prevents infection." "A snug fit is needed to minimize scarring and to smooth the skin." "Perhaps the garment should be resized." "The garment can be removed for an hour each day."

"A snug fit is needed to minimize scarring and to smooth the skin."

An adult client with a burn injury just arrived at the emergency department. Place the nursing actions in the care of this client in order of priority. All options must be used. Select the correct sequence number for each item. 1. Assess for airway patency. 2. Obtain vital signs. 3. Administer oxygen as prescribed. 4. Elevate the extremities. 5. Keep the client warm. 6. Initiate an intravenous (IV) line and begin fluid replacement as prescribed.

1, 3, 2, 6, 4, 5

prepu A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned? 18% 36% 30% 27%

36%

An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury? 18% 24% 36% 48%

36% According to the rule of nines, with the initial burn, the anterior half of the head equals 4.5%, the upper half of the anterior torso equals 9%, and the lower half of both arms equals 9%. The subsequent burn included the posterior half of the head, equaling 4.5%, and the upper half of the posterior torso, equaling 9%. This totals 36%.

prepu A client has sustained a severe burn injury and is thought to have an impaired intestinal mucosal barrier. What intervention will best assist in avoiding increased intestinal permeability and prevent early endotoxin translocation? Bowel-cleansing procedures Early enteral feeding Administration of stool softeners Administration of prophylactic antibiotics

7:30 p.m. to 9:30 p.m.; 24 to 36 hours he greatest volume of fluid loss occurs in the first 24 to 36 hours after the burn, peaking by 6 to 8 hours.

ati A nurse is planning care for a client who has deep partial-thickness and full-thickness thermal burns over 40% of his total body surface and is in the acute phase of burn injury. Which of the following interventions should the nurse include in the plan? A. Initiate range-of-motion exercises B. Use clean technique to provide wound care C. Place the client on a low-protein diet D. Maintain the client on bed rest

A. Initiate range-of-motion exercisesa

ati A nurse is evaluating the laboratory values of a client who is in the resuscitation phase following a major burn. Which of the following laboratory findings should the nurse expect? A. Hemoglobin 10 g/dL B. Sodium 132 mEq/L C. Albumin 3.6 g/dL D. Potassium 4.0 mEq/dL

B. Sodium 132 mEq/L

The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury? Decreased heart rate Increased urinary output Increased blood pressure Elevated hematocrit levels

Elevated hematocrit levels

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? Superficial Full-thickness Deep partial-thickness Partial-thickness superficial

Full-thickness 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.

Which of the following is to be expected soon after a major burn? Select all that apply. Hypotension Tachycardia Bradycardia Hypertension Anxiety

Hypotension Tachycardia Anxiety

A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mm Hg, a pulse rate of 110 beats/minute, and a urine output of 20 mL over the past hour. The nurse reports the findings to the primary health care provider (PHCP) and anticipates which prescription? Transfusing 1 unit of packed red blood cells Administering a diuretic to increase urine output Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour Changing the IV lactated Ringer's solution to one that contains 5% dextrose in water

Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour

prepu Which zone of burn injury sustains the most damage? Middle Inner Protective Outer

Inner

The nurse has developed a nursing care plan for a client with a burn injury to implement during the emergent phase. Which priority intervention should the nurse include in the plan of care? Monitor vital signs every 4 hours. Monitor mental status every hour. Monitor intake and output every shift. Obtain and record weight every other day

Monitor mental status every hour.

A nurse is aware that after a burn injury and respiratory difficulties have been managed, the next most urgent need is to: Measure hourly urinary output. Prevent renal shutdown. Replace lost fluids and electrolytes. Monitor cardiac status.

Replace lost fluids and electrolytes.

The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy? Vital signs Urine output Mental status Peripheral pulses

Urine output