chapter 23 PREP U (ONLY BURNS!)

If dressings adhere to the wound, soak in hot water before removal.

Which is an important consideration for the nurse when changing dressings and applying topical medication to a childs abdomen and leg burns?

Burn-wound infection

Which of the following is the most common complication seen in children during the recovery-management phase of burn treatment?

establish an airway start IV fluids provide for pain relief place a foley catheter

A child has sustained a severe burn. Place the following nursing interventions in the order of what would be done for this child when the medical team arrived on the scene.

tetanus

A child is admitted to the acute care facility with a burn injury. The nurse would check the child's immunization status, specifically for which of the following?

inhalation injury

A child is admitted with extensive burns. The nurse notes that there are burns on the childs lips and singed nasal hairs. The nurse should suspect that the child has a(n):

infection prevention

A child is hospitalized with burns over 25% of the body. The nurse is preparing to perform a dressing change. What aspect of changing the child's dressings is most important for the nurse to consider?

Acknowledge that the client is upset and offer to talk about feelings.

A nurse is providing care to a 13-year-old client hospitalized with deep partial- and full-thickness (deep second-degree and third-degree) burns on the neck, torso and arms. The nurse attempts to begin a treatment, but the client refuses and angrily tells the nurse "What is the point in all this? I will never be the same again!" What action should the nurse take?

Insert a nasogastric tube. Administer a proton pump inhibitor. Offer the child's favorite foods. Initiate total parenteral nutrition.

A nurse is reviewing a plan of care for a 5-year-old child hospitalized with severe burns. Due to systemic changes that occur secondary to the burn injuries, what intervention(s) related to nutrition should the nurse expect to implement? Select all that apply.

8-year-old with an inhalation injury 6-year-old with burns involving the knees and hips 10-year-old with second-degree (partial-thickness) burns over 15% of the body 9-year-old with asthma and burns to the face

A nurse is working as part of a response team caring for children who have been involved in an elementary school fire. Which children would the nurse identify as needing a referral to a burn unit? Select all that apply.

Urine output of 15 ml per hour over the last 4 hours

The nurse is caring for a child on the burn unit weighing 100 lb (45.5 kg) who has second-degree (partial-thickness) burns over 30% of the body. During the beginning shift assessment, which assessment finding is of most concern to the nurse?

"I will give it to ny child at least 1 hour before all meals."

The nurse is caring for a child with a prescription for PO prednisone. Which statement by the child's mother would indicate a need for further education?

full-thickness or third-degree

The nurse is assessing a child who pulled a boiling pot of soup off of the stove top. The child reports pain at a 9 on a scale of 0 to 10. The burn is red and edematous, and also shows areas of charred skin. The nurse is aware that these signs and symptoms are indicative of what kind of burn?

stocking-glove pattern on hands or feet

The nurse is caring for a 7-year-old with burns. Which finding would be highly suggestive of a burn induced by child abuse (child maltreatment)?

Blisters appear.

The nurse is caring for a child admitted with second-degree (partial-thickness) burns. What is most characteristic of this type of burn?

Soak the old dressing in tepid water before attempting to remove.

The nurse is caring for a client with burns in a pediatric hospital. The child is scheduled to be discharged the following day and the nurse is going over discharge education with the parents. Which is the best intervention for the parents when removing an old dressing?

Acute pain related to thermal injuries and procedures

The nurse is developing the plan of care for a child who has suffered a major burn and has just been admitted to the acute care facility. Which nursing diagnosis would be most appropriate?

Provide around-the-clock pain medication as soon as pain is reported.

Which intervention is the most beneficial for a burn client undergoing a skin graft?

Give child as many choices as possible.

Which is an effective strategy to reduce the stress of burn dressing procedures?

disorientation

Which is one of the first signs of overwhelming sepsis in a child with burn injuries?

34

The nurse is monitoring the intake and output of a client with deep partial-thickness or second-degree burns. The child weighs 75 lb (34 kg). The nurse will contact the physician if the child's urine output drops below how many milliliters per hour? (Round you answer to the nearest whole number.)

Hold burned area under cool running water.

A toddler sustains a minor burn on the hand from hot coffee. Which is the first action the nurse should recommend in treating this burn?

Pain

The nurse is completing the care plan for a pediatric client with deep partial-thickness or second-degree burns on the back and legs. Debridement of the burns is performed 2 to 3 times per week. What nursing diagnosis has the highest priority in regard to this treatment modality?

A 17-year-old adolescent states no longer using the tanning bed after attending the presentation. A 15-year-old adolescent states always using sunscreen because "she does not want to get skin cancer like my mother did." A 16-year-old adolescent states that it "scares me to think that my cells are changing when I get a sunburn."

The student nurse gives a presentation on the dangers of sun exposure to clients at a community health center. Which statement(s) by the attendees demonstrate that knowledge was gained from the presentation? Select all that apply.

Make arrangements to transfer the child to the hospital.

A 2-year-old child is brought to the urgent care center for treatment of burns on both hands. The parent reports that the child pulled the coffee pot over and the hot liquid splashed on to the child's hands. The nurse examines the child and notes that the backs of the hands are reddened with a well-defined line of demarcation at the wrists. Several medium to large blisters are also present. What initial action should the nurse take?

The child's respiratory rate is 42 breaths/min.

A 3-year-old child is admitted after being severely burned. The nurse collects the following data. What finding would be most important for the nurse to report immediately?

protein

A child has sustained a minor burn. Which of the following should be included in increased amounts in the child's diet?

reduce pain

A child with extensive burns requires debridement. The nurse should anticipate which priority goal related to this procedure?

Administer diphenhydramine.

A nurse is caring for a child with second- and third-degree (partial- and full-thickness) burns over 15% of the body. The child reports severe itching in and around the burn sites. Which action would be most appropriate for the nurse to perform?

Second-degree or partial-thickness burn

A young child has just been admitted to the emergency department with a burn that encompasses the epidermis and the underlying dermis. From which type of burn does this child suffer?

Cleanse the wound with a mild soap and tepid water.

A young child has sustained a minor burn to the foot. Which is recommended for treatment of a minor burn?

Remove her burned clothes and jewelry

An adolescent girl is cooking on a gas stove when her bathrobe catches fire. Her father smothers the flames with a rug and calls an ambulance. She has sustained major burns over much of her body. Which is important in her immediate care?

Provide pain relief.

Fentanyl and midazolam (Versed) are given before dbridement of a childs burn wounds. Which is the rationale for administration of these medications?

Debridement of the wounds

Hydrotherapy is required to treat a child with extensive partial-thickness burn wounds. Which is the primary purpose of hydrotherapy?

provide anesthesia

Nitrous oxide is being administered to a child with extensive burn injuries. Which is the purpose of this medication?

shock

The most immediate threat to life in children with thermal injuries is:

Hypertrophic scarring

The nurse explains to the parents of a child with a severe burn that wearing an elastic pressure garment (Jobst stocking) during the rehabilitative stage can help with the prevention of:

Skin assessment involves inspection and palpation in a room with natural daylight.

What is the best technique to perform an assessment of the skin?

Destruction of all layers of skin evident with extension into subcutaneous tissue

Which best describes a full-thickness (third-degree) burn?

Increased capillary permeability

Which explains physiologically the edema formation that occurs with burns?

Risk for altered tissue perfusion

Which of the following would be the priority nursing diagnosis during the acute phase of burn injury for a child who has a third-degree circumferential burn of the right arm?

Provide around the clock pain medication.

A child with a burn injury is scheduled for skin grafting. Which intervention would be most appropriate for the nurse to include in the child's plan of care?

Airway remains patent.

A nurse is providing care to an infant who is admitted with burns over the face, neck and chest. The nurse identifies which goal as priority for planning the infant's care

The diet will avoid protein breakdown.

A parent of a child with major burns asks the nurse why a high-calorie and high- protein diet is prescribed. Which response should the nurse make?

Apply cold compresses to the area.

A school-aged child is brought to the office of the camp nurse with a small, superficial burn (first-degree burn). Which action by the nurse would be most appropriate to take first?

infection

After the acute stage and during the healing process, the primary complication from burn injury is:

temperature 100.5°F (38.1°C)

An intensive care nurse has received the above hand-off report from the emergency department nurse. Thirty minutes later, the nurse assesses the child again. Which assessment finding should the nurse investigate further?

observing wounds for signs of infection

Biologic dressings are applied to a child with partial-thickness burns of both legs. Which nursing intervention should be implemented?

hypermetabolism elevated catecholamines hyperglycemia

The nurse is caring for a child with burn injury who has been admitted to the acute care facility. When assessing this child, which metabolic changes would the nurse expect to find? Select all that apply.

Acute pain related to thermal injuries and procedures

The nurse is caring for a child with burns in a pediatric hospital. What would be an appropriate nursing diagnosis for this client?

100.5 -First, the nurse divides the total amount of fluid by 2, because there are two doses. (3216 mL ÷ 2 = 1608 ml) -Next, the nurse divides the single dose amount by the total number of hours, which is 16. (1608 mL ÷ 16 hours = 100.5 ml/hour)

A nurse is providing care to a hospitalized child who has burns over 40% of the body. The child is receiving intravenous fluid replacement with a 24 hour total of 3,216 ml. The nurse is administering the second half of the fluid between 0100 and 1700 hours. What rate should the nurse set the infusion pump? Record your answer using one decimal place.

Administer pain medication as prescribed.

The nurse is caring for a 9-year-old child with partial-thickness (second-degree) burns. The client rates the pain at an 8 on a 1 to 10 numerical pain scale. The nurse notes the client is sitting in the bed playing with toys and smiling. Which action will the nurse take?

Quickly run cool water over the toddler's hands. Cover the burns with a clean nonadhesive bandage. Set up an appointment with the health care provider.

A toddler pulled a cup of hot coffee off the table, causing first-degree (superficial) burns on the hands. The parent calls the clinic and asks what actions to take. How should the nurse respond? Select all that apply.

"I guess my mom was right; she always put ice on our burns when we were kids."

The school nurse has completed an educational program on first aid practices in the home. Which statement about burn care by a participant would indicate a need for further education?

Encourage the parent to talk more about feelings.

A parent is observing a nurse provide care for the parent's 2-year-old toddler who was burned in a house fire. When the nurse is finished, the parent tells the nurse "I cannot believe this has happened. I should have been able to prevent this from happening." What is the best action for the nurse to take?