Burns Questions

Administer morphine sulfate 10 mg IV. Débride the wound of eschar using gauze sponges. Obtain specimens for aerobic and anaerobic wound cultures. Apply silver sulfadiazine ointment. Cover the wound with a sterile gauze dressing.

The nurse is performing a sterile dressing change for a client with infected deep partial-thickness burns of the chest and abdomen. List the steps in the order in which each should be accomplished.

c

The nurse is receiving report on a client with chemical burns over 70% of the body. The outgoing nurse states that the client's pain is a 7/10. The client has been averaging 80 ml/hr out of urine output and receiving 125 ml/hr 0.9% normal saline into a central venous catheter. The serum sodium is 133, K is 3.4, and Mag is 1.9. Vital signs are stable. The client is receiving antibiotics and is on a regular diet. What is the nurse's primary concern? A.Magnesium level B.Diet C.Pain D.Urine output

a

What is the best method to prevent auto contamination for a 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.Use sterile gloves when changing dressings

3

12. The client is being discharged after being in the burn unit for six (6) weeks. Which strategies should the nurse identify to promote the client's mental health? 1. Encourage the client to stay at home as much as possible. 2. Discuss the importance of not relying on the family for needs. 3. Tell the client to remember that changes in lifestyle take time. 4. Instruct the client to discuss feelings only with the therapist.

d

A client is recovering from an injury in which he was severely burned. The client is having difficulties coping with his appearance and he tells the nurse that he does not want to look at the burned area. Which response from the nurse is most appropriate? A.Tell the client about reconstructive surgery options B.Explain that the client's friends and family can support him C.Encourage the client to get rid of all mirrors in the home D.Encourage the client to talk about his feelings

a

A nurse in a provider's office is assessing a client who has a severe sunburn. Which of the following is the proper classification of this burn? a. Superficial b. Superficial partial-thickness c. Deep partial-thickness d. Full-thickness

1

10. The client is admitted with full-thickness and partial-thickness burns to more than 30% of the body. The nurse is concerned with the client's nutritional status. Which intervention should the nurse implement? 1. Encourage the client's family to bring favorite foods. 2. Provide a low-fat, low-cholesterol diet for the client. 3. Monitor the client's weight weekly in the same clothes. 4. Make a referral to the hospital social worker.

123

14. The nurse is preparing the plan of care for a client diagnosed with Stevens-Johnson syndrome. Which interventions should the nurse include? Select all that apply. 1. Monitor intake and output every eight (8) hours. 2. Assess breath sounds and rate every four (4) hours. 3. Assess vesicles, erosions, and crusts frequently. 4. Perform the whisper test for auditory changes daily. 5. Assess orientation to person, place, and time every shift.

4

2. The client with full-thickness burns to 40% of the body, including both legs, is being transferred from a community hospital to a burn center. Which measure should be instituted before the transfer? 1. A 22-gauge intravenous line with normal saline infusing. 2. Wounds covered with moist sterile dressings. 3. No intravenous pain medication. 4. Ensure adequate peripheral circulation to both feet.

42315

26. The ED nurse is caring for a client admitted with extensive, deep partial-thickness and fullthickness burns. Which interventions should the nurse implement? List in order of priority. 1. Estimate the amount of burned area using the rule of nines. 2. Insert two (2) 18-gauge catheters and begin fluid replacement. 3. Apply sterile saline dressings to the burned areas. 4. Determine the client's airway status. 5. Administer morphine sulfate, IV.

1

3. The client has full-thickness burns to 65% of the body, including the chest area. After establishing a patent airway, which collaborative intervention is priority for the client? 1. Replace fluids and electrolytes. 2. Prevent contractures of extremities. 3. Monitor urine output hourly. 4. Prepare to assist with an escharotomy.

a

A client who has been severely burned in an accident is brought to the emergency department. The physician orders a regimen to begin fluid resuscitation. Which type of fluid would the nurse most likely use as part of fluid resuscitation following a burn injury? A.LR B.NS C.D10W D.D5.45NS w/ KCL

3

4. The nurse is applying mafenide acetate (Sulfamylon), a sulfa antibiotic cream, to a client's lower extremity burn. Which assessment data would require immediate attention by the nurse? 1. The client complains of pain when the medication is administered. 2. The client's potassium level is 3.9 mEq/L and sodium level is 137 mEq/L. 3. The client's ABGs are pH 7.34, Pao2 98, Paco2 38, and HCO3 20. 4. The client is able to perform active range-ofmotion exercises.

3

5. The client is scheduled to have a xenograft to a left lower-leg burn. The client asks the nurse, "What is a xenograft?" Which statement by the nurse would be the best response? 1. "The doctor will graft skin from your back to your leg." 2. "The skin from a donor will be used to cover your burn." 3. "The graft will come from an animal, probably a pig." 4. "I think you should ask your doctor about the graft."

1

6. The intensive care unit (ICU) burn nurse is developing a nursing care plan for a client with severe full-thickness and deep partial-thickness burns over half the body. Which client problem has priority? 1. High risk for infection. 2. Ineffective coping. 3. Impaired physical mobility. 4. Knowledge deficit.

2

7. The nurse writes the nursing diagnosis "impaired skin integrity related to open burn wounds." Which intervention would be appropriate for this nursing diagnosis? 1. Provide analgesia before pain becomes severe. 2. Clean the client's wounds, body, and hair daily. 3. Screen visitors for respiratory infections. 4. Encourage visitors to bring plants and flowers.

abe

An emergency department nurse is caring for a client with 2nd and 3rd degree burns on 40 percent of his body. The nurse knows that the effects of the burn on the cardiovascular system include which of the following? Select all that apply. A.Hypovolemic shock B.Increased heart rate C.Increased BP D.Increased urine output E.Fluid volume deficit

all

During the acute phase of the burn injury, the patient may have initial problems that extend into the acute phase and may develop new problems. The priority collaborative problems for patients with burn injuries greater than 25% TBSA in the acute phase of recovery include: (SATA) 1. Wound care management due to impaired TISSUE INTEGRITY associated with burn injury and skin grafting procedures 2. Potential for infection of open burn wounds due to the presence of multiple invasive catheters, reduced immune function, and poor NUTRITION 3. Weight loss due to increased metabolic rate, reduced calorie intake, and increased urinary nitrogen losses 4. Decreased MOBILITY due to open burn wounds, pain, scars, and contractures 5. Decreased self-esteem due to trauma, changes in physical appearance and lifestyle, and alterations in sensory and motor function

b

Four members involved in a house fire have been admitted to the ED. Which client should the RN see first? A.18-year-old with 25% TBSA burns to the back and arms B.45-year-old with 30% TBSA burns to chest and arms and face C.60-year-old with 40% TBSA burns to lower body D. 5 year old with 30% burns to arms, legs, and back

d

The client asks about ways to prevent carbon monoxide poisoning. Which teaching will the nurse provide? A. "You can see black smoke when carbon monoxide is in the air." B. "If you are experiencing carbon monoxide poisoning, your skin will begin to turn blue." C. "The only way to get poisoned from carbon monoxide gas is if you are in the presence of a fire." D. "It is important to have carbon monoxide detectors in your home because this is an odorless gas."

bde

The nurse is encouraging range-of-motion exercises for the client, who states, "This hurts terribly; I don't want to do this." Identify the appropriate nursing response(s). Select all that apply. A. "You have to do the exercises to get well." B. "Range of motion helps promote mobility." C. "Just visualize a beach to get your mind off of the pain." D. "Let me check when you were last given pain medication." E. "Which techniques for pain management have you used in the past that were helpful?" F. "The health care provider has ordered these exercises, and it is important that you do them as instructed."

A each leg = 18% 2x18% = 36%

The nurse is working in the emergency department when a patient is brought in with burns from the bathtub to both legs. The nurse knows that this constitutes burns to what percentage of the body? A.36% B.9% C.27% D.12%

d

Which assessment finding does the nurse interpret as demonstrating a client's fluid resuscitation adequacy? A. Decreased skin turgor B. Decreased pulse pressure C. Decreased core body temperature D. Decreased urine specific gravity

3

Which client is best for the nurse manager on the burn unit to assign to an RN who has floated from the oncology unit? 1. A 23-year-old client who has just been admitted with burns over 30% of the body after a warehouse fire 2. A 36-year-old client who requires discharge teaching about nutrition and wound care after having skin grafts 3. A 45-year-old client with infected partial-thickness back and chest burns who has a dressing change scheduled 4. A 57-year-old client with full-thickness burns on both arms who needs assistance in positioning hand splints

c

Which clinical assessment findings would be an early indication of hypovolemia? a. BP was 147/70 now is 160/90, RR was 18 now 24 b. Urine output 40 now 30 mL/hr, HR was 96 BPM now is 88 BPM. c. RR was 18/min now 28/min, HR was 78 BPM now is 99 BPM. d, HR was 70 BPM now is 52 BPM, client complains of restlessness.

c

Which of the actions by the LPN requires the RN to intervene immediately while caring fora client on protective isolation for a burn injury? a. The LPN is providing the client with clean sheets and linens. b. The LPN is performing strict hand washing technique. c. The LPN is delivering a vase of flowers to the client. d. The LPN is wearing gloves and a gown when assisting with wound dressing changes.

ade

from the patient would the nurse attend to as highest priority? Select all that apply. A.The client has an oxygen saturation of 87 percent on room air B.The client has a 3-inch bandaged laceration on the shoulder C.The client complains of pain in the right arm D.The client has singed hairs around the mouth and nose E.The client has retractions in the chest with breathing

2

1. The client comes into the emergency department in severe pain and reports that a pot of boiling hot water accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin, and both feet are edematous. Which depth of burn should the nurse document? 1. Superficial partial thickness. 2. Deep partial thickness. 3. Full thickness. 4. First degree.

2

11. The client sustained a hot grease burn to the right hand and calls the emergency department for advice. Which information should the nurse provide to the client? 1. Apply an ice pack to the right hand. 2. Place the hand in cool water. 3. Be sure to rupture any blister formation. 4. Go immediately to the doctor's office.

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8. Which nursing interventions should be included for the client who has full-thickness and deep partial-thickness burns to 50% of the body? Select all that apply. 1. Perform meticulous hand hygiene. 2. Use sterile gloves for wound care. 3. Wear gown and mask during procedures. 4. Change central lines once a week. 5. Administer antibiotics as prescribed.

4

9. The nurse is caring for a client with deep partialthickness and full-thickness burns to the chest area. Which assessment data would warrant notifying the health-care provider? 1. The client is complaining of severe pain. 2. The client's pulse oximeter reading is 95%. 3. The client has T 100.4oF, P 100, R 24, and BP 102/60. 4. The client's urinary output is 50 mL in two (2) hours.

b 170 lbs / 2.2 = 77.27 4 x 77 x 40= 12,200 mL = 12 L

A client is brought into the emergency department after suffering from third-degree burns in an explosion. The client has burns on approximately 40 percent of his body. The nurse weighs the client and notes that he weighs 170 lbs. Calculate the volume of IV fluid this client must receive in the first 24 hours using the Parkland formula. A.8L B.12L C.16L D.3L

2

A client who has extensive blister injuries to the back and both legs caused by exposure to toxic chemicals at work is transferred to the emergency department. Which prescribed intervention will the nurse implement first? 1. Infuse lactated Ringer's solution at 250 mL/hr. 2. Rinse the back and legs with 4 L of sterile normal saline. 3. Obtain blood for a complete blood count and electrolyte levels. 4. Document the percentage of total body surface area burned.

c

A nurse is caring for a client who has sustained burns to 35% of his total body surface area. Of this total, 20% are full-thickness burns of the arms, face neck and shoulders. The client's voice is hoarse, and he has a brassy cough. These findings are indicative of which of the following? a. Pulmonary edema b. Bacterial pnemonia c. Inhalation injury d. Carbon monoxide poisoning

acd

A nurse is caring for a client who was admitted 24 hr ago with deep partial-thickness and full-thickness burns to 40% of his body. Which of the following are expected findings in this client? (select all that apply) a. Temperature 36.1 (97) b. Bradycardia c. Hyperkalemia d. Hyponatremia e. Decreased hematcrit

ace

A nurse is planning care for a client who has burn injuries. Which of the following interventions should be included in the plan of care? (select all that apply) a. Use standard precautions when performing wound care. b. Encourage fresh vegetables in the diet. c. Increase protein intake. d. Instruct client to consume 3,000 calories daily. e. Restrict fresh flowers in room.

c

A nurse is preparing to administer fentanyl (Sublimaze) to a client who was admitted 24 hr ago with deep partial-thickness and full-thickness burns over 60% of his body. The nurse should plan to use which of the following routes to administer the medication? a. Subcutaneous b. Intramuscular c. Intravenous d. Transdermal

c

A patient was brought into the emergency department with 2nd and 3rd degree burns over 36% of his body. What is the priority during this initial emergency department phase in caring for this client? A.Pain control B.Promote normothermia C.Fluid resuscitation D.Wound debridement

2

The nurse has just received a change-of-shift report for the burn unit. Which client should be assessed first? 1. Client with deep partial-thickness burns on both legs who reports severe and continuous leg pain 2. Client who has just arrived from the emergency department with facial burns sustained in a house fire 3. Client who has just been transferred from the postanesthesia care unit after having skin grafts applied to the anterior chest 4. Client admitted 3 weeks ago with full-thickness leg and buttock burns who has been waiting for 3 hours to receive discharge teaching

3

The nurse has just received the change-of-shift report in the burn unit. Which client requires the most immediate assessment or intervention? 1. A 22-year-old client admitted 4 days previously with facial burns due to a house fire who has been crying since recent visitors left 2. A 34-year-old client who returned from skin-graft surgery 3 hours ago and is reporting level 8 pain (on a scale of 0 to 10) 3. A 45-year-old client with partial-thickness leg burns who has a temperature of 102.6°F (39.2°C) and a blood pressure of 98/46 mm Hg 4. A 57-year-old client who was admitted with electrical burns 24 hours ago and has a blood potassium level of 5.1 mEq/L (5.1 mmol/L)

4

The priority collaborative problems for patients with burn injuries in the resuscitation phase who have sustained a burn injury greater than 25% of the TBSA include: 1. Potential for decreased oxygenation due to upper airway edema, pulmonary edema, airway obstruction, or pneumonia 2. Potential for shock due to increase in capillary permeability, active fluid volume loss, electrolyte imbalance, and inadequate fluid resuscitation 3. Pain (acute and chronic) due to tissue injury, damaged or exposed nerve endings, débridement, dressing changes, invasive procedures, and donor sites 4. Potential for acute respiratory distress syndrome (ARDS) due to inhalation injury

b

Which of these assessments indicates the expected outcome of the fluid resuscitation for a client with a burn injury? a. HR increased from 58 to 110. b. Urine output was 28 mL/hr now 60 mL/hr. c. Decreased level of consciousness. d. Peripheral pulses 1+ bilaterally.

d

Which of these clients is a priority to assess immediately after shift report? a. A client admitted with an abnormal skin lesion that has grown in size over the last month. b. A client who was in a house fire 2h hours ago who is resting quietły. c. The client who is scheduled for their dressing changes for a pressure ulcer. d. A client with full thickness burn to his chest and is complaining of shortness of breath and chest pain.

b

Which of these represents the correct fluid replacement schedule using the Parkland Baxter Formula requiring 4000 mL. during the first 24 hours for a client with severe burns? a. 160 mL/hr x 8 then 190 mL/hr x 8, and then 200 mL/hr x 8. b. 250 mL/hr x 8, then 125 mL/hr x 8, and then 25 mL/hr x 8. c. 245 mL/hr x 8 then 190 mL/hr x 8, and then 100 mL/hr x8 d. 167 mL/hr x 8 167 mL./hr x 8 and then 167 ml./hr x 8.