Ch 57: Management of Patients with Burn Injury

c) Application of ice Pg. 1874 Application of ice causes vasoconstriction and diminishes needed blood flow to the zone of injury. Clothing and hair are removed from perimeter of burned area in an effort to remove course of bacterial contamination. Irrigation of the wound assists in the removal of debris.

1. Initial first aid rendered at the scene of a fire includes preventing further injury through heat exposure. Which intervention could contribute to tissue hypoxia and necrosis and therefore should be avoided? a) Irrigation of the wound b) Removal of hair c) Application of ice d) Removal of clothing

a) Epidermis and a portion of deeper dermis Pg. 1867 A deep partial-thickness burn includes the epidermis, upper dermis, and a portion of the deeper dermis. A burn limited to the epidermal layer is classified as a superficial partial-thickness burn. The last two choices refer to a full-thickness burn.

19. 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: a) Epidermis and a portion of deeper dermis b) Entire dermis and subcutaneous tissue c) Dermis and connective tissue d) Epidermal layer only

b) Natural Pg. 1881 Natural debridement is accomplished when nonliving tissue sloughs away from uninjured tissue. Mechanical debridement involves the use of surgical tools to separate and remove the eschar. Enzymatic debridement encompasses the use of topical enzymes to the burn wound. Surgical debridement uses the use of forceps and scissors during dressing changes or wound cleaning.

2. Which type of debridement occurs when nonliving tissue sloughs away from uninjured tissues? a) Enzymatic b) Natural c) Mechanical d) Surgical

c) BUN: 28 mg/dL Pg. 1877-1879 The elevated BUN would cause the nurse the most concern. The nurse should report decreased urine output or increased BUN and creatinine values to the physician. These laboratory values indicate possible renal failure. In addition, myoglobinuria, associated with electrical burns, is common with muscle damage and may also cause kidney failure if not treated. The other values are within normal limits.

3. A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern? a) Na+: 145 mEq/L b) K+: 5.0 mEq/L c) BUN: 28 mg/dL d) Ca: 9 mg/dL

a) Dry and pale white Pg. 1867 The wound appearance for a full-thickness burn would be dry, pale white, leathery, or charred.

30. A nurse helps a health care provider treat a full-thickness burn on a patient's hand. Prior to treatment, the nurse documents the appearance of the wound as: a) Dry and pale white b) Broken epidermis that is weeping c) Reddened; blanches with pressure d) Blistered with a mottled red base

a) Skin turgor b) Hourly urine output d) Daily weights Pg. 1885 Monitoring of hourly urine output and daily weights provides clues about fluid volume status. Skin turgor is a sign of fluid loss (dehydration). Percentage of meals eaten, and oxygen saturation would not be reliable indicators of fluid volume status in the client.

31. The nurse recognizes that which of the following provide clues about fluid volume status? Select all that apply. a) Skin turgor b) Hourly urine output c) Oxygen saturation d) Daily weights e) Percentage of meals eaten

d) Irrigate the wounds with water Pg. 1874 The nurse should begin treatment by irrigating the wounds with water. Delaying treatment until the agent is identified allows the agent to cause further tissue damage. Washing the wounds with soap and water might cause a chemical reaction that may further damage tissue. The client may require I.V. fluid; however, the wounds should be irrigated first.

32. A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene? a) Insert a 20-gauge I.V. catheter and infuse normal saline solution at 150 ml/hour b) Wash the wounds with soap and water and apply a barrier cream d) Do nothing until the chemical agent is identified d) Irrigate the wounds with water

d) Tetracycline Pg. 1881 Silver sulfadiazine (Silvadene), mafenide (Sulfamylon), and silver nitrate (AgNO3) 0.5% solution are the three major antimicrobials used to treat burns.

33. Which antimicrobials is not commonly used to treat burns? a) Mafenide (Sulfamylon) b) Silver nitrate (AgNO3) 0.5% solution c) Silver sulfadiazine (Silvadene) d) Tetracycline

b) Stasis Pg. 1869 The zone of stasis is the area of intermediate burn injury. It is here that blood vessels are damaged, but tissue has the potential to survive. The zone of coagulation is at the center of the injury, and it is the area where the injury is most severe and usually deepest. The zone of hyperemia is the area of least injury, where the epidermis and dermis are only minimally damaged. The zone of hypotension is not the name of one of the zones.

34. 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: a) Hypotension b) Stasis c) Hyperemia d) Coagulation

d) Inner Pg. 1869 Each burned area has three zones of injury. The inner area (known as the zone of coagulation, where cellular death occurs) sustains the most damage. The middle area, or zone of stasis, has a compromised blood supply, inflammation, and tissue injury. The outer zone, the zone of hyperemia, sustains the least damage.

35. Which zone of burn injury sustains the most damage? a) Outer b) Protective c) Middle d) Inner

a) Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel Pg. 1874 After the flames are extinguished, the burned area and adherent clothing are soaked with cool water, briefly, to cool the wound and halt the burning process.

5. A person suffers leg burns from spilled charcoal lighter fluid. A family member extinguishes the flames. While waiting for an ambulance, what should the burned person do? a) Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel b) Remove his burned pants so that the air can help cool the wound c) Lie down, have someone cover him with a blanket, and cover his legs with petroleum jelly d) Sit in a chair, elevate his legs, and have someone cut his pants off around the burned area

c) Full-thickness Pg. 1867 A full-thickness burn injury heals by contraction or epithelial migration and requires grafting. The other types of burn injury do not require skin grafting.

50. Which type of burn injury requires skin grafting? a) Superficial partial-thickness b) Deep partial-thickness c) Full-thickness d) Superficial

b) Paralytic ileus Pg. 1873 Patients who are critically ill, including those with burns, are predisposed to altered gastrointestinal (GI) motility for many reasons, which may include impaired enteric nerve and smooth muscle function, inflammation, surgery, medications, and impaired tissue perfusion. Three of the most common GI alterations in burn-injured patients are paralytic ileus (absence of intestinal peristalsis), Curling's ulcer, and translocation of bacteria. Decreased peristalsis and bowel sounds are manifestations of paralytic ileus.

51. 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? a) Diverticulitis b) Paralytic ileus c) Ulcerative colitis d) Hematemesis

d) Music therapy may provide reality orientation, distraction, and sensory stimulation Pg. 1883-1884 Researchers have found that music affects both the physiologic and psychological aspects of the pain experience. Music diverts the client's attention away from the painful stimulus. Music may also provide reality orientation, distraction, and sensory stimulation. It allows for client self-expression. Humor therapy has proven effective in the management of burn pain. Pet therapy has not proven effective in the management of burn pain.

52. The nurse determines which statement reflects current research regarding the utilization of nonpharmacological measures in the management of burn pain? a) Music therapy diverts the client's attention toward painful stimulus b) Humor therapy has not proven effective in the management of burn pain c) Pet therapy has proven effective in the management of burn pain d) Music therapy may provide reality orientation, distraction, and sensory stimulation

a) Cardiac dysrhythmia Pg. 1870 Cardiac dysrhythmias are common for victims of electrical burns. If the patient has an electrical burn, a baseline electrocardiogram (ECG) is obtained and continuous monitoring is initiated. Any burn injury can lead to complications, such as inhalation injury, infection, and hypovolemic shock.

53. Which complication is common for victims of electrical burns? a) Cardiac dysrhythmia b) Inhalation injury c) Infection d) Hypovolemic shock

b) 1% Pg. 1868-1869 In clients with scattered burns, or for a quick prehospital assessment, the Palmer method may be used to estimate the extent of the burns. The size of the client's palm, including the surface area of the digits, is approximately 1% of the total body surface area.

54. When using the Palmer method to estimate the extent of a small or scattered burn injury, the nurse recognizes the palm is equal to which percentage of total body surface area? a) 4% b) 1% c) 2% d) 3%

a) Skin grafting will be necessary Pg. 1867 In a full-thickness burn, all layers of the skin are destroyed and will result in the need for skin grafts. Full-thickness burns are painless. A deep partial-thickness burn may take 3 or more weeks to heal. In the most serious full-thickness burns, ligaments, tendons, muscles, and bone may be involved.

55. The client is admitted with full-thickness burns to the forearm. Which is the most accurate interpretation made by the nurse? a) Skin grafting will be necessary b) Pain management will be a challenge c) The wound will take up to 3 weeks to heal d) Ligaments, tendons, muscles, and bone are not involved

a) Neck and chest Pg. 1882 Skin grafting is essential for deep partial-thickness burns on the client's neck and chest because the skin layers responsible for regeneration have been destroyed. The client's face does not need skin grafting because the burns are superficial and will heal unassisted.

70. A client with superficial burns on the face and deep partial-thickness burns on the neck and chest is undergoing treatment and is anxious to know about skin grafting. For which of the following areas can skin grafting be suggested? a) Neck and chest b) Face and neck c) Face, neck, and chest d) Face only

a) As soon as foul odor or purulent drainage is noted, or 2 to 5 days after surgery Pg. 1882 A foul odor or purulent drainage may indicate infection and should be reported to the surgeon immediately. The first dressing change usually occurs 2 to 5 days after surgery. Sanguineous drainage on a dressing covering an autograft is an anticipated abnormal observation postoperatively.

71. The nurse recognizes the first dressing change at the site of an autograft is performed a) As soon as foul odor or purulent drainage is noted, or 2 to 5 days after surgery b) As soon as sanguineous drainage is noted c) Within 12 hours after surgery d) Within 24 hours after surgery

b) Sunburn Pg. 1867 A potential cause of a superficial partial-thickness burn is a sunburn or low-intensity flash. Causes of deep partial-thickness burns are scalds and flash flames. Full-thickness burns may be caused by an electrical current or prolonged exposure to hot liquids.

72. Which of the following is a potential cause of a superficial partial-thickness burn? a) Flash flame b) Sunburn c) Scald d) Electrical current

b) 2 to 5 days after surgery Pg. 1882 The first dressing change usually occurs 2 to 5 days after surgery. In addition, a foul odor or purulence may indicate infection and should be reported to the surgeon immediately. Sanguineous drainage on a dressing covering an autograft is an anticipated abnormal observation postoperatively.

73. A client has undergone grafting following a burn injury. The nurse understands that the first dressing change at the site of an autograft is performed how soon after the surgery? a) Within 12 hours after surgery b) 2 to 5 days after surgery c) As soon as sanguineous drainage is noted d) Within 24 hours after surgery

c) The early appearance of the burn injury may change Pg. 1868 The nurse is required to reassess and revise the estimate of burn depth because the early appearance of the burn injury may change. Assessing the burn depth helps determine the potential of the damaged tissue to survive. It does not establish the percentage of the TBSA that is burned or minimize the risk of infections. It also does not help determine whether the client's condition is likely to deteriorate after 72 hours.

8. 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? a) It helps determine the percentage of the total body surface area (TBSA) that is burned b) The wound is susceptible to infections c) The early appearance of the burn injury may change d) The client's condition is likely to deteriorate after 72 hours

c) 18% Pg. The rule-of-nines system is based on dividing anatomic regions, each representing approximately 9% of the total body surface area (TBSA), quickly allowing clinicians to obtain an estimate. If a portion of an anatomic area is burned, the TBSA is calculated accordingly—for example, if approximately half of the anterior leg is burned, the TBSA burned would be 4.5%. More specifically, with an adult who has been burned, the percent of the body involved can be calculated as follows: head = 9%, chest (front) = 9%, abdomen (front) = 9%, upper/mid/low back and buttocks = 18%, each arm = 9% (front = 4.5%, back = 4.5%), groin = 1%, and each leg = 18% total (front = 9%, back = 9%). In this case the client's abdomen (9%) and front of the left leg (9%) add up to 18%.

9. A client presents to the emergency department following a burn injury. The client has burns to the abdomen and front of the left leg. Using the rule of nines, the nurse documents the total body surface area percentage as a) 9% b) 27% c) 18% d) 36%

d) Serum sodium level of 140 mEq/L Pg. 1871 In the acute/intermediate (fluid remobilization) phase of burn care, sodium is lost with water due to diuresis, and existing serum sodium is diluted with water influx, resulting in a decreased serum sodium level. Normal serum sodium level is 135 to 145 mEq/L, so 140 mEq/L is a normal finding, which is unexpected in the acute/intermediate phase of burn care. Normal hematocrit, metabolic acidosis, and hypokalemia are all expected findings during this phase.

10. What laboratory value observed by the nurse is unexpected during the fluid remobilization phase of a major burn? a) Hematocrit level of 45% b) Serum potassium level of 3.2 mEq/L c) A pH of 7.20, PaO2 of 38 mm Hg, and bicarbonate level of 15 mEq/L d) Serum sodium level of 140 mEq/L

a) 27% Pg. 1868 The TBSA would be 27%. That is 18% of the body surface for the anterior trunk and 9% for the left arm.

11. A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned? a) 27% b) 45% c) 18% d) 36%

b) Severe burning pain for up to 20 minutes Pg. 1881 The patient should be premedicated with analgesic before applying mafenide acetate because this agent causes severe burning pain for up to 20 minutes after application. Silver nitrate stains everything it touches black. Acticoat dressings can be left in place for 3 to 5 days. Silver nitrate solution acts as a wick for sodium and potassium; serum levels of these electrolytes need to be monitored.

12. A patient has been prescribed mafenide acetate cream for burn treatment. The nurse should educate the patient regarding which of the following? a) Blood levels of sodium and potassium will be monitored b) Severe burning pain for up to 20 minutes c) Stains clothing d) Can be left in place for 3 to 5 days

d) 27% Pg. 1868 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 his back (18%) and one arm (9%), totaling 27% of his body.

13. A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body? a) 9% b) 36% c) 18% d) 27%

a) Decreased catabolism Pg. 1885 Burn injuries produce profound metabolic abnormalities fueled by the exaggerated stress response to the injury. The body's response has been classified as hyperdynamic, hypermetabolic, and hypercatabolic. 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. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50%. A marked increase in metabolic rate is seen after a burn injury and interventions are instituted to decrease metabolic rate and catabolism. A marked increase in glucose demand is seen after a burn injury and interventions are instituted to decrease glucose demands and catabolism. Rapid skeletal muscle breakdown with amino acids serving as the energy source is seen after a burn injury and interventions are instituted to decrease catabolism.

20. 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 a) Decreased catabolism b) Increased glucose demands c) Increased skeletal muscle breakdown d) Increased metabolic rate

b) A urinary output of 30 mL/hr Pg. 1877 For adults, a urine output of 30 to 50 mL per hour is used as an indication of appropriate resuscitation in thermal and chemical injuries, whereas in electrical injuries a urine output of 75 to 100 mL per hour is the goal (ABA, 2011a).

21. 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) A urinary output of 10 mL/hr b) A urinary output of 30 mL/hr c) A urinary output of 80 mL/hr d) A urinary output of 100 mL/hr

a) Fluid resuscitation Pg. 1874 Fluid resuscitation requirements are paramount in the management of clients having burns that exceed 20% of TBSA. Fluid resuscitation with crystalloid and colloid solutions is calculated from the time the burn injury occurred to restore the intravascular volume and prevent hypovolemic shock and renal failure. Infection prevention is a care consideration with all burns. Endotracheal tube placement may be necessary if respiratory factors indicate the need. Intake and output records are maintained to determine the success of fluid resuscitation efforts.

14. A client is brought to the ED with burns exceeding 20% of total body surface area. Which is the primary nursing intervention in the care of this client? a) Fluid resuscitation b) Strict intake and output c) Endotracheal tube placement d) Prevent infection

c) Related to circumferential eschar Pg. 1871 As edema develops on circumferential burns, eschar forms a tight, constricting band, compromising circulation to the extremity distal to the circumferential site and impairing physical mobility. This client isn't likely to develop fat emboli unless long bone or pelvic fractures are present. Infection doesn't alter physical mobility. A client with burns on the lower portions of both legs isn't likely to have femoral artery occlusion.

15. 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? a) Related to fat emboli b) Related to infection c) Related to circumferential eschar d) Related to femoral artery occlusion

d) Superficial Pg. 1867 A superficial burn only damages the epidermis. A full-thickness burn involves total destruction of the dermis and extends into the subcutaneous fat. It can also involve muscle and bone. In a superficial partial-thickness burn, the epidermis is destroyed and a small portion of the underlying dermis is injured. A deep partial-thickness burn extends into the reticular layer of the dermis and is hard to distinguish from a full-thickness burn. It is red or white, mottled, and can be moist or fairly dry.

16. A patient has a burn injury that has damaged the epidermis. There are no blisters, and the skin is pink in color. This type of burn injury would be documented as which of the following? a) Superficial partial-thickness b) Full-thickness c) Deep partial-thickness d) Superficial

a) Risk for impaired gas exchange Pg. 1873 During the initial assessment of a burn victim, the nurse must look for evidence of inhalation injury. Once oxygen saturation and respirations are determined, pain intensity is evaluated. The assessment of damage to the tissues and prevention of infection are secondary to airway issues.

17. 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? a) Risk for impaired gas exchange b) Acute pain c) Infection risk d) Altered tissue perfusion

b) Immerse the child's legs in cool water Pg. 1867 The application of cool water is the best first-aid measure. Soaking the burned area intermittently in cool water or applying cool towels gives immediate and striking relief from pain and limits local tissue edema and damage.

18. A child tips a pot of boiling water onto his bare legs. The mother should: a) Liberally apply butter or shortening to the burned areas b) Immerse the child's legs in cool water c) Avoid touching the burned skin and take the child to the nearest emergency department d) Cover the child's legs with ice cubes secured with a towel

b) The client has experienced extensive full-thickness burns Pg. 1867 In full-thickness burns, nerves are damaged and consequently painless. Behavior change is not a significant symptom of hypovolemic shock. Opioids are used in the management of pain associated with partial-thickness burns but not significant in the behavior exhibited. Partial-thickness burns are associated with increased pain to the area of involvement.

22. 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? a) The client is in hypovolemic shock b) The client has experienced extensive full-thickness burns c) The paramedic administered high doses of opioids during transport d) The client has experienced partial-thickness burns

a) Hypotension c) Anxiety d) Tachycardia Pg. 1875-1876 Tachycardia, slight hypotension, and anxiety are expected soon after the burn.

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

a) Preexisting conditions Pg. 1968 Preexisting disease disorders including trauma and infections can modify the inflammatory response and movement of fluid from the vascular to the interstitial space. Age, weight, and family history are not as significant in the inflammatory response following a burn.

24. 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? a) Preexisting conditions b) Weight c) Age d) Family history

b) Roll the client in a blanket Pg. 1882 At the scene of a fire, the client should be rolled in a blanket to smother the fire. The client should be placed in a horizontal position to prevent the fire, hot air, and smoke from rising toward the head and entering the respiratory passage. The client should not be covered immediately with a wet cloth or kept in any position other than horizontal. However, IV fluid therapy should be administered en route to the hospital.

25. Which intervention helps to minimize the risk of further injury to an affected person at the scene of a fire? a) Avoid immediate IV fluid therapy b) Roll the client in a blanket c) Place the client with the head positioned slightly below the rest of the body d) Cover the client with a wet cloth

b) Escharotomy Pg. 1871 Debridement is the removal of necrotic tissue. An escharotomy is an incision into the eschar to relieve pressure on the affected area. An allograft would not be the treatment. Silvadene may be part of the treatment regimen but not specifically for this situation.

26. A client has a third-degree burn on the leg. The wound is being treated by the open method. After about 4 days, a hard crust has formed around the leg and is impairing the circulation to the leg. What procedure would be done to relieve pressure on the affected area? a) Debridement b) Escharotomy c) Silvadene application d) Allograft

d) Hemoconcentration Pg. 1872 The client with a burn experiences hemoconcentration when the plasma component of blood is lost or trapped. Myoglobin and hemoglobin are transported to the kidneys, where they may cause tubular necrosis and acute renal failure.

27. A client who was severely burned begins to exhibit symptoms of renal failure during treatment. What physiologic process can cause acute renal failure? a) Fluid, electrolyte status b) Anemia c) Histamine d) Hemoconcentration

b) Hyperkalemia Pg. 1871 Immediately after burn injury, hyperkalemia (excessive potassium) may result from massive cell destruction. Hypokalemia (potassium depletion) may occur later with fluid shifts and inadequate potassium replacement. During burn shock, serum sodium levels vary in response to fluid resuscitation. Hyponatremia (serum sodium depletion) may be present as a result of plasma loss. Hyponatremia may also occur during the first week of the acute phase, as water shifts from the interstitial space and returns to the vascular space.

28. The nurse is caring for a client 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 if it occurs immediately after burn injury? a) Hypokalemia b) Hyperkalemia c) Hypernatremia d) Hypercalcemia

b) 2,400 mL Pg. 1874 The ABA consensus formula provides for the volume of an isotonic solution (e.g., lactated Ringer's [LR]) to be administered during the first 24 hours in a range of 2 mL/kg/percentage TBSA. Half of the calculated total should be given over the first 8 postburn hours, and the other half should be given over the next 16 hours. Thus, the equation to find the minimum amount to infuse for this scenario is as follows: 2 mL × 80 kg × 30 = 4,800 mL of solution to be administered in the first 24 hours, with half this amount, 2,400 mL, to be administered in the first 8 hours.

29. A sample consensus formula for fluid replacement recommends that a balanced salt solution be administered in the first 24 hours of a chemical burn in the range of 2 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? a) 3,600 mL b) 2,400 mL c) 4,800 mL d) 1,200 mL

b) 36% Pg. 1868 According to the rule of nines, the anterior portion of the lower extremity is 9% and the posterior portion of the lower extremity is 9%. Each lower extremity is therefore equal to 18%. Both lower extremities that have sustained burns to entire surfaces will equal to 36% of total surface area.

36. 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? a) 18% b) 36% c) 27% d) 9%

b) Apply a cervical collar on the client Pg. 1874-1875 Until it is known that the client has no fractures, it is imperative that a neck collar be applied and remain in place and that the client is log rolled to eliminate the chance of further spinal cord injury. With high-voltage electrical injuries, cervical spine immobilization is a priority until cervical spine injury is ruled out. The other interventions may be completed; however, the priority intervention is to apply the collar.

37. A client is brought to the emergency department by a coworker following a burn injury from a high-voltage electrical power line. The triage nurse determines which intervention should be completed first? a) Obtain a 12-lead ECG b) Apply a cervical collar on the client c) Insert a urinary Foley catheter d) Take the client's vital signs

a) Gastric ulcers Pg. 1873 The release of histamine as a consequence of the stress response increases gastric acidity. The client with a burn is prone to develop gastric (Curling's) ulcers. Anemia develops because of the heat destroying the erythrocytes. Release of histamine does not cause hyperthyroidism or cardiac arrest.

38. A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client? a) Gastric ulcers b) Anemia c) Cardiac arrest d) Hyperthyroidism

c) Hemodilution Pg. 1872 Reduced hematocrit is caused by hemodilution 48 hours after a burn, in which volume overload resulting from interstitial-to-plasma fluid shift lowers the concentration of erythrocytes and other blood elements. Hemoconcentration results from hypoalbuminemia, which causes the movement of fluid from the vascular component to the interstitial space. Metabolic acidosis does cause the red blood cell components to be fragile, but it isn't related to reduced hematocrit level in this situation. Erythropoietin factor is reduced if kidney failure occurs; however, lack of erythropoietin factor doesn't affect hematocrit level.

39. A nurse provides care for a client with deep partial-thickness burns 48 hours after the burn. What would cause a reduced hematocrit in this client? a) Metabolic acidosis b) Hemoconcentration c) Hemodilution d) Lack of erythropoietin factor

a) 36% Pg. 1868 The Rule of Nines divides body surface area into percentages that, when totaled, equal 100%. According to the Rule of Nines, the arms account for 9% each, the anterior legs account for 9% each, and the anterior trunk accounts for 18%. Therefore, this client's burns cover 36% of the body surface area.

4. 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? a) 36% b) 18% c) 27% d) 30%

a) Wash the wound with soap and water c) Report increased redness and wound drainage to the healthcare provider e) Continue physical therapy exercises Pg. 1880 The client being discharged with burn wound care needs to demonstrate wound care technique; take prescribed pain medications if needed 30 minutes prior to wound care to achieve maximum effectiveness; use mild soap, water, and a clean washcloth to clean wounds; apply prescribed topical medications( not lubricating lotions to the wound bed) and dressings as instructed; inspect wounds carefully with each dressing change for signs of infection, including increased redness, swelling, drainage, or foul odor; and state aspects of activities of daily living as per therapy.

40. A nurse is providing discharge teaching for a client with a burn wound on the leg. What instructions are important to give the client? Select all that apply. a) Wash the wound with soap and water b) Apply lubricating lotion to the wound bed c) Report increased redness and wound drainage to the healthcare provider d) Take pain medications daily e) Continue physical therapy exercises

a) Place the client in a horizontal position b) Roll the client in a blanket to smother the fire Pg. 1874 If the clothing is on fire, the client is placed in a horizontal position and rolled in a blanket to smother the fire.

41. At the scene of a fire, the first priority is to prevent further injury. What are interventions at the site that can help to prevent injury? Select all that apply. a) Place the client in a horizontal position b) Roll the client in a blanket to smother the fire c) Open a door and encourage air in an enclosed space d) Place the client in a vertical position

d) Sulfadiazine, silver (Silvadene) Pg. 1881 With use of silver sulfadiazine (Silvadene), the nurse should watch for leukopenia 2 to 3 days after initiation of therapy. (Leukopenia usually resolves within 2 to 3 days.)

42. The nurse is providing wound care for a client with burns to the lower extremities. Which topical antibacterial agent carries a side effect of leukopenia that the nurse should monitor for within 48 hours after application? a) Gentamicin sulfate b) Cerium nitrate solution c) Mafenide (Sulfamylon) d) Sulfadiazine, silver (Silvadene)

b) "This medication will be applied directly to the wound" c) "This medication will help my burn heal" d) "This medication is an antibacterial" Pg. This medication is an antibacterial, which has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. This medication is directly applied to the wound. This medication will not stain the client's skin, but it will help heal the client's burned areas.

43. 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. a) "This medication will stain my skin permanently" b) "This medication will be applied directly to the wound" c) "This medication will help my burn heal" d) "This medication is an antibacterial"

c) Biobrane Pg. 1883 Biobrane is a nylon-silicone membrane coated with a protein. Mederma is a topical gel that can reduce scarring. Integra consists of a two-layer membrane: one is a synthetic epidermal layer , and the other contains cross-linked collagen fibers that mimic the dermal layer of skin. Transcyte is created by culturing human fibroblasts from the dermis with a biosynthetic semipermeable membrane attached to nylon mesh.

44. Which of the following skin substitutes is a nylon-silicone membrane coated with a protein? a) Integra b) Mederma c) Biobrane d) Transcyte

b) Reduction in blood volume Pg. 1876 A reduction in blood volume occurs secondary to plasma loss. Sodium deficit, potassium excess, and decreased urinary output occurs in this phase.

45. Which of the following fluid or electrolyte changes occur in the emergent/resuscitative phase? a) Increased urinary output b) Reduction in blood volume c) Potassium deficit d) Sodium excess

c) 1% Pg. 1869 A quick assessment technique is to compare the client's palm with the size of the burn wound. The palm is approximately 1% of a person's TBSA.

46. The palm represents which percentage of a person's TBSA? a) 10% b) 5% c) 1% d) 15%

b) Lactated Ringer's solution Pg. 1874 Lactated Ringer's solution replaces lost sodium and corrects metabolic acidosis, both of which commonly occur following a burn. Albumin is used as adjunct therapy, not as primary fluid replacement. D5W isn't given to burn clients during the first 24 hours because it can cause pseudodiabetes. The client is hyperkalemic as a result of the potassium shift from the intracellular space to the plasma, so giving potassium would be detrimental.

47. A client has partial-thickness burns on both lower extremities and portions of the trunk. Which IV fluid does the nurse plan to administer first? a) Dextrose 5% in water (D5W) b) Lactated Ringer's solution c) Normal saline solution with 20 mEq of potassium per 1,000 ml d) Albumin

b) Application of cool water Pg. 1874 Once a burn has been sustained, the application of cool water is the best first-aid measure. Never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns.

48. Which of the following measures can be used to cool a burn? a) Wrapping the person in ice b) Application of cool water c) Application of ice directly to burn d) Using cold soaks or dressings for at least 1 hour

b) Circulatory status Pg. 1876 During the acute phase of a burn, the nurse should assess the client's circulatory and respiratory status, vital signs, fluid intake and output, ability to move, bowel sounds, wounds, and mental status. Information about the client's lifestyle and alcohol and tobacco use may be obtained later when the client's condition has stabilized.

49. During the acute phase of a burn, a nurse should assess: a) The client's lifestyle b) Circulatory status c) Alcohol use d) Tobacco use

d) The client's complete blood count readings reflect a reduced hematocrit Pg. 1876 During the intermediate phase of burn care, the client's hematocrit should diminish as a result of hemodilution, which occurs as the fluids shift back into the circulating blood volume from the tissues. In the intermediate phase of burn care, the client will experience serum sodium deficits. Urinary output increases during this phase as renal perfusion increases. Loss of serum sodium leads to metabolic acidosis, not metabolic alkalosis.

56. A nurse is preparing a care plan for a client burned over 36% of his body 2 days ago. Which clinical manifestation indicates that the client has progressed into the intermediate phase of burn care? a) The client's urinary output has fallen below 30 ml/hour b) The client's serum sodium levels are elevated c) The client exhibits metabolic alkalosis d) The client's complete blood count readings reflect a reduced hematocrit

d) Full thickness (third degree) Pg. 1867 Full-thickness (third degree) burn destroys all layers of the skin and consequently is painless. The tissue appearance varies and can be dry, pale white, red, brown, leathery, charred or lifeless. Superficial (first degree) burn is similar to a sunburn. The epidermis is injured, but the dermis is unaffected. Superficial partial-thickness burn heals within 14 days, with possibly some pigmentary changes but no scarring. The deep partial-thickness (second degree) burn takes more than 3 weeks to heal, may need debridement, and is subject to hypertrophic scarring. A fourth-degree burn can involve ligaments, tendons, muscles, nerves, and bone.

57. 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 leathery. How would the nurse document the depth of burn injury this client has? a) Superficial partial-thickness or deep partial-thickness (second degree) b) Superficial (first degree) c) Fourth degree d) Full thickness (third degree)

a) Hyperkalemia Pg. 1871 Circulating blood volume decreases dramatically during burn shock due to severe capillary leak with variation of serum sodium levels in response to fluid resuscitation. Usually, hyponatremia (sodium depletion) is present. Immediately after burn injury, hyperkalemia (excessive potassium) results from massive cell destruction. Hypokalemia (potassium depletion) may occur later with fluid shifts and inadequate potassium replacement.

58. Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is: a) Hyperkalemia b) Hypernatremia c) Hypocalcemia d) Hypoglycemia

c) Hoarseness of the voice Pg. 1877 Hoarseness is indicative of injury to the respiratory system and could indicate the need for immediate intubation. Thirst following burns is expected because of the massive fluid shifts and resultant loss, leading to dehydration. Pain, either severe or moderate, is expected with a burn injury. The client's urine output is adequate.

59. When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately? a) Complaints of intense thirst b) Moderate to severe pain c) Hoarseness of the voice d) Urine output of 70 ml the first hour

d) Face, neck, chest Pg. Burns of the face, neck, or chest have the potential to impair ventilation due to their proximity to the areas where breathing occurs.

6. Specific potential complications are common to specific types of burns. Which burns can impair ventilation? a) Perineal b) Legs c) Hands, major joints d) Face, neck, chest

b) Pulmonary system Pg. 1874-1875 Airway patency and breathing must be assessed during the initial minutes of emergency care. Immediate therapy is directed toward establishing an airway and administering humidified 100% oxygen. Pulmonary problems may be caused by the inhalation of heat and/or smoke or edema of the airway. Assessing a patent airway is always a priority after a burn injury followed by breathing. Remember the ABCs.

60. Following a burn injury, the nurse determines which area is the priority for nursing assessment? a) Nutrition b) Pulmonary system c) Cardiovascular system d) Pain

b) Myoglobin in the urine Pg. 1875-1876 Myoglobin from muscle tissue destruction is transported to the kidneys for excretion and can cause tubular necrosis and acute renal failure. Increase in fluid intake until urine output clears is recommended in serious burns. An increase in ADH release is expected as the body tries to prevent hypovolemic shock. Elevation in glucose levels occurs when the adrenal cortex is stimulated. Sodium levels rise in response to aldosterone levels, which directly leads to peripheral edema.

61. Which of the following would indicate the need to increase fluids beyond what is recommended for fluid resuscitation? a) Hypernatremia b) Myoglobin in the urine c) Increase in antidiuretic hormone (ADH) d) Elevation of blood glucose levels

c) To keep fire and smoke from airway Pg. 1874 The primary reason the client is placed in a horizontal position while smothering flames is to prevent the fire, hot air, and smoke from rising toward the head and entering the respiratory passages. The stop, drop, and roll method is a quick and efficient means to extinguish flames. If hypovolemic shock occurs, lowering the head will assist in promoting blood flow to the head.

62. Which is the primary reason for placing a client in a horizontal position while smothering flames are present? a) To extinguish flames more quickly b) To promote blood flow to the brain and vital organs c) To keep fire and smoke from airway d) To prevent collapse and further injuries

d) "It reduces the risk of complications from an infection" Pg. 42 Early surgical excision to remove devitalized tissue along with early burn wound closure has long been recognized as one of the most important factors contributing to survival in a client with a major burn injury. When conducted in a timely and efficient manner, surgical excision results in shorter lengths of hospital stay and decreased risk of complications from invasive burn wound sepsis. Surgical debridement is not done to reduce the amount of scarring or the amount of wound care that will be needed. Natural debridement is a bodily process that liquefies any damaged tissue and may take weeks to months to occur.

63. A client with a burn over the lower leg asks why surgery is planned to remove the dead burned tissue. Which response will the nurse make? a) "It reduces the amount of wound care that you will need as the skin heals" b) "It reduces the amount of scarring that will occur on the skin" c) "It encourages your body's natural processes to liquefy any damaged tissue" d) "It reduces the risk of complications from an infection"

d) A urine output consistently above 40 ml/hour Pg. 1874 In a client with burns, the goal of fluid resuscitation is to maintain a mean arterial blood pressure that provides adequate perfusion of vital structures. If the kidneys are adequately perfused, they will produce an acceptable urine output of at least 0.5 ml/kg/hour. Thus, the expected urine output of a 155-lb client is 35 ml/hour, and a urine output consistently above 40 ml/hour is adequate. Weight gain from fluid resuscitation isn't a goal. In fact, a 4-lb weight gain in 24 hours suggests third spacing. Body temperature readings and ECG interpretations may demonstrate secondary benefits of fluid resuscitation but aren't primary indicators.

64. 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) A weight gain of 4 lb (2 kg) in 24 hours b) Body temperature readings all within normal limits c) An electrocardiogram (ECG) showing no arrhythmias d) A urine output consistently above 40 ml/hour

d) Instruct to pat and not scratch the areas Pg. 54 Post-burn pruritus (itching) affects almost all clients with burns and is one of the most distressing symptoms in the post-burn period. The client should be instructed to "pat, don't scratch" in order to prevent further discomfort and infectious complications. Other actions to reduce the itching include oral antipruritic agents, environmental conditions, frequent lubrication of the skin with water or silica-based lotion, and diversion activities. Warm compresses will enhance the itching. Elevating the extremities above the level of the heart helps reduce edema. Pain medication is not used to treat pruritis.

65. A client recovering from burn injuries over both forearms reports itching of the wounds. Which action will the nurse take to enhance the client's comfort? a) Provide pain medication as needed b) Apply warm compresses over the areas c) Elevate the extremities above heart level d) Instruct to pat and not scratch the areas

d) Allograft Pg. 1883 Allograft or homograft is a biologic source of skin similar to that of the client. A xenograft or heterograft is obtained from animals, principally pigs or cows. An autograft uses the client's own skin, transplanted from one part of the body to another. A slit graft is a type of autograft.

66. Several temporary and permanent sources are available for covering a burn wound. These may be manufactured synthetically, obtained from a biologic source, or a combination of the two. Which graft is described as a biologic source of skin similar to that of the client? a) Xenograft b) Autograft c) Slit graft d) Allograft

d) Premedicating the client with an analgesic prior to application Pg. 1881 Mafenide is a strong carbonic anhydrase inhibitor and may cause metabolic acidosis. Application may cause considerable pain initially, thus premedicating the client is an appropriate intervention. The other nursing implications are not associated with mafenide.

67. A client with a burn wound is prescribed mafenide acetate 5% twice daily. Nursing implications associated with this medication include a) Monitoring the client's Na+ and K+ serum levels and replace as prescribed b) Protecting the bed linens and client's clothing from contact to prevent staining c) Monitoring the client for the development of respiratory acidosis d) Premedicating the client with an analgesic prior to application

a) Pain management Pg. 1867 With a superficial partial-thickness burn such as a solar burn, the nurse's main concern is pain management. Fluid resuscitation and infection become concerns if the burn extends to the dermal and subcutaneous skin layers. Body image disturbance is a concern that has lower priority than pain management.

68. 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: a) Pain management b) Fluid resuscitation c) Infection d) Body image

d) "A snug fit is needed to minimize scarring and to smooth the skin" Pg. 1889 The forming of burn scars can be minimized by the use of pressure dressings and custom-fitted garments that apply continuous pressure. Garments need to be snug in order to be effective. These garments are worn for 23 hours a day and may be prescribed for as long as 2 years. Prevention of infection is not indicated with use.

69. 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? a) "The garment can be removed for an hour each day" b) "The garment acts as a skin layer and prevents infection" c) "Perhaps the garment should be resized" d) "A snug fit is needed to minimize scarring and to smooth the skin"

d) The client's urinary output is 0.5 mL/kg/hour Pg. 1874 Successful fluid resuscitation is gauged by a urinary output of 0.5 mL/kg/hour via an indwelling catheter. Fluid resuscitation does not directly affect the client's heart rate, breathing, or mental status.

7. 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? a) The client's heart rate is rapid b) The client's breathing is unlabored and skin is clammy c) The client is conscious d) The client's urinary output is 0.5 mL/kg/hour