Burns
A client is admitted to the hospital after sustaining burns to the chest, abdomen, right arm, and right leg. Using the "rule of nines," estimate what percentage of the client's body surface has been burned. 18% 27% 45% 64%
Correct answer 45% Feedback According to the rule of nines, this client has sustained burns on about 45% of the body surface. The right arm is calculated as being 9%, the right leg is 18%, and the anterior trunk is 18%, for a total of 45%. Score: 1 / 1
The client with a major burn injury receives total parenteral nutrition (TPN). What is the expected outcome of TPN? Correct water and electrolyte imbalances. Allow the gastrointestinal tract to rest. Provide supplemental vitamins and minerals. Ensure adequate caloric and protein intake.
Correct answer Ensure adequate caloric and protein intake. Feedback Nutritional support with sufficient calories and protein is extremely important for a client with severe burns because of the loss of plasma protein through injured capillaries and an increased metabolic rate. Gastric dilation and paralytic ileus commonly occur in clients with severe burns, making oral fluids and foods contraindicated. Water and electrolyte imbalances can be corrected by administration of IV fluids with electrolyte additives, although TPN typically includes all necessary electrolytes. Resting the gastrointestinal tract may help prevent paralytic ileus, and TPN provides vitamins and minerals; however, the primary reason for starting TPN is to provide the protein necessary for tissue healing.
The nurse is assessing an 80-year-old client who has scald burns on the hands and both forearms (first- and second-degree burns on 10% of the body surface area). What should the nurse do first? Clean the wounds with warm water. Apply antibiotic cream. Refer the client to a burn center. Cover the burns with a sterile dressing.
Correct answer Refer the client to a burn center. Feedback The nurse should have the client transported to a burn center. The client's age and the extent of the burns require care by a burn team, and the client meets triage criteria for referral to a burn center. Because of the age of the client and the extent of the burns, the nurse should not treat the burn. Scald burns are not at high risk for infection and do not need to be cleaned, covered, or treated with antibiotic cream at this time.
What should the nurse assess the client for during the early phase of burn care? hypernatremia hyponatremia metabolic alkalosis hyperkalemia
Correct answer hyperkalemia Feedback Immediately after a burn, excessive potassium from cell destruction is released into the extracellular fluid. Hyponatremia is a common electrolyte imbalance in the burn client that occurs within the first week after being burned. Metabolic acidosis usually occurs as a result of the loss of sodium bicarbonate.
In the acute phase of burn injury, which pain medication would most likely be given to the client to decrease the perception of the pain? oral analgesics such as ibuprofen or acetaminophen intravenous opioids intramuscular opioids oral antianxiety agents such as lorazepam
Correct answer intravenous opioids Feedback The severe pain experienced by burn clients requires opioid analgesics. In addition, opioids such as morphine sedate and alleviate apprehension. Oral analgesics such as ibuprofen or acetaminophen are unlikely to be strong enough to effectively manage the intense pain experienced by the client who is severely burned. Because of the altered tissue perfusion from the burn injury, intravenous medications are preferred. Antianxiety agents are not effective against pain.
The nurse is caring for a client with severe burns who is receiving fluid resuscitation. Which finding indicates that the client is responding to the fluid resuscitation? pulse rate of 112 bpm blood pressure of 94/64 mm Hg urine output of 30 mL/h serum sodium level of 136 mEq/L (136 mmol/ L)
Correct answer urine output of 30 mL/h Feedback Ensuring a urine output of 30 to 50 mL/h is the best measure of adequate fluid resuscitation. The heart rate is elevated, but this is not an indicator of adequate fluid balance. The blood pressure is low, likely related to the hypovolemia, but urinary output is the more accurate indicator of fluid balance and kidney function. The sodium level is within normal limits.
After the initial phase of the burn injury, what goals should the nurse establish with the client? helping the client maintain a positive self-concept promoting hygiene preventing infection educating the client regarding care of the skin grafts
Correct answer preventing infection Feedback The inflammatory response begins when a burn is sustained. As a result of the burn, the immune system becomes impaired. There is a decrease in immunoglobulins, changes in white blood cells, alterations of lymphocytes, and decreased levels of interleukin. The human body's protective barrier, the skin, has been damaged. As a result, the burn client becomes vulnerable to infections. Education and interventions to maintain a positive self-concept would be appropriate during the rehabilitation phase. Promoting hygiene helps the client feel comfortable; however, the primary focus is on reducing the risk for infection.
During the emergent (resuscitative) phase of burn injury, which finding indicates that the client requires additional volume with fluid resuscitation? serum creatinine level of 2.5 mg/dL (221 µmol/ L) little fluctuation in daily weight hourly urine output of 60 mL serum albumin level of 3.8 mg/dL (38 g/L)
Correct answer serum creatinine level of 2.5 mg/dL (221 µmol/ L) Feedback Fluid shifting into the interstitial space causes intravascular volume depletion and decreased perfusion to the kidneys. This would result in an increase in serum creatinine. Urine output should be frequently monitored and adequately maintained with intravenous fluid resuscitation that would be increased when a drop in urine output occurs. Urine output should be at least 30 mL/h. Fluid replacement is based on the Parkland or Brooke formula and also the client's response by monitoring urine output, vital signs, and CVP readings. Daily weight is important to monitor for fluid status. Little fluctuation in weight suggests that there is no fluid retention and the intake is equal to output. Exudative loss of albumin occurs in burns, causing a decrease in colloid osmotic pressure. The normal serum albumin is 3.5 to 5 g/dL (35 to 50 g/L).
Which client with burns will most likely require an endotracheal or tracheostomy tube?A client who has: electrical burns of the hands and arms causing arrhythmias. thermal burns to the head, face, and airway resulting in hypoxia. chemical burns on the chest and abdomen. secondhand smoke inhalation.
Correct answer thermal burns to the head, face, and airway resulting in hypoxia. Feedback Airway management is the priority in caring for a burn client. Tracheostomy or endotracheal intubation is anticipated when significant thermal and smoke inhalation burns occur. Clients who have experienced burns to the face and neck usually will be compromised within 1 to 2 hours. Electrical burns of the hands and arms, even with cardiac arrhythmias, or a chemical burn of the chest and abdomen is not likely to result in the need for intubation. Secondhand smoke inhalation does influence an individual's respiratory status but does not require intubation unless the individual has an allergic reaction to the smoke.
A client is admitted with a 45% partial and full thickness burn. Which finding would alert the nurse that the client has a deficiency in fluid volume during the first 24 hours? serum creatinine of 1.1 mg/dL (97.2 μmol/L) serum potassium level of 3.7 mEq/L oxygen saturation of 94% urine output of <30 mL/h
Correct answer urine output of <30 mL/h Feedback It is critical that the nurse monitor the vital signs, hemodynamics and urine output during the emergent and resuscitative phase of the burn injury. The urine output of <30 mL/h is an indication of hypovolemia in this client. The serum creatinine, serum potassium, and the oxygen saturation level are all within acceptable limits.
