Chapter 57: Management of Patients with Burn Injury PrepU
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? · The client's urinary output is 0.5 mL/kg/hour. · The client's heart rate is rapid. · The client's breathing is unlabored and skin is clammy. · The client is conscious.
A Explanation: 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.
A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern? · BUN: 28 mg/dL · Ca: 9 mg/dL · K+: 5.0 mEq/L · Na+: 145 mEq/L
A Explanation: 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.
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? · Urine output of 20 ml/hour · Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg · Rectal temperature of 100.4° F (38° C) · White pulmonary secretions
A · Explanation: · A urine output of less than 30 ml/hour in a client with burns indicates a deficient fluid volume. This client's PaO2 value falls within the normal range (80 to 100 mm Hg). White pulmonary secretions are normal. The client's rectal temperature isn't significantly elevated, and the slight increase in temperature probably results from the deficient fluid volume.
A nurse is aware that after a burn injury and respiratory difficulties have been managed, the next most urgent need is to: · Replace lost fluids and electrolytes. · Prevent renal shutdown. · Measure hourly urinary output. · Monitor cardiac status.
A · Explanation: · After managing respiratory difficulties, the next most urgent need is to prevent irreversible shock by replacing lost fluids and electrolytes. The total volume and rate of IV fluid replacement are gauged by the patient's response and guided by the resuscitation formula.
Which intervention helps to minimize the risk of further injury to an affected person at the scene of a fire? · Roll the client in a blanket · Cover the client with a wet cloth · Place the client with the head positioned slightly below the rest of the body · Avoid immediate IV fluid therapy
A · Explanation: · 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.
A client with deep partial-thickness and full-thickness burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse provides additional client teaching because these exercises may: · dislodge the autografts. · increase edema in the arms. · increase the amount of scarring. · decrease circulation to the fingers.
A · Explanation: · Because exercising the autograft sites may dislodge the grafted tissue, the nurse should advise the client to keep the grafted extremity in a neutral position. Exercise doesn't cause increased edema, increased scarring, or decreased circulation.
Specific potential complications are common to specific types of burns. Which burns can impair ventilation? · face, neck, chest · hands, major joints · legs · perineal
A · Explanation: · Burns of the face, neck, or chest have the potential to impair ventilation due to their proximity to the areas where breathing occurs.
Which complication is common for victims of electrical burns? · Cardiac dysrhythmia · Infection · Inhalation injury · Hypovolemic shock
A · Explanation: · 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.
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? · "It reduces the risk of complications from an infection." · "It reduces the amount of scarring that will occur on the skin." · "It reduces the amount of wound care that you will need as the skin heals." · "it encourages your body's natural processes to liquefy any damaged tissue."
A · Explanation: · 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.
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? · Hyperkalemia · Hypokalemia · Hypercalcemia · Hypernatremia
A · Explanation: · 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.
A client with a burn wound is prescribed mafenide acetate 5% twice daily. Nursing implications associated with this medication include · premedicating the client with an analgesic prior to application. · monitoring the client's Na+ and K+ serum levels and replace as prescribed. · protecting the bed linens and client's clothing from contact to prevent staining. · monitoring the client for the development of respiratory acidosis.
A · Explanation: · 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.
Which of the following measures can be used to cool a burn? · Application of cool water · Using cold soaks or dressings for at least 1 hour · Application of ice directly to burn · Wrapping the person in ice
A · Explanation: · 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.
Which antimicrobials is not commonly used to treat burns? · tetracycline · silver sulfadiazine (Silvadene) · mafenide (Sulfamylon) · silver nitrate (AgNO3) 0.5% solution
A · Explanation: · Silver sulfadiazine (Silvadene), mafenide (Sulfamylon), and silver nitrate (AgNO3) 0.5% solution are the three major antimicrobials used to treat burns.
A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene? · Irrigate the wounds with water. · Do nothing until the chemical agent is identified. · Wash the wounds with soap and water and apply a barrier cream. · Insert a 20-gauge I.V. catheter and infuse normal saline solution at 150 ml/hour.
A · Explanation: · 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.
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 · 18%. · 9%. · 36%. · 27%.
A · Explanation: · 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%.
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: · stasis. · hypotension. · hyperemia. · coagulation.
A · Explanation: · 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.
The nurse is applying an occlusive dressing to a burned foot. What position should the foot be placed in after application of the dressing? · Adduction · Dorsiflexion · Plantar flexion · External rotation
A · Explanation: · When occlusive dressings are applied, precautions are taken to prevent two body surfaces from touching, such as fingers or toes, ear and scalp, the areas under the breasts, any point of flexion, or between the genital folds.
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? · Sulfadiazine, silver (Silvadene) · Gentamicin sulfate · Cerium nitrate solution · Mafenide (Sulfamylon)
A · Explanation: · 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.)
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. · Place the client in a horizontal position. · Roll the client in a blanket to smother the fire. · Place the client in a vertical position. · Open a door and encourage air in an enclosed space.
A,B · Explanation: · If the clothing is on fire, the client is placed in a horizontal position and rolled in a blanket to smother the fire.
The nurse recognizes that which of the following provide clues about fluid volume status? Select all that apply. · Hourly urine output · Daily weights · Percentage of meals eaten · Skin turgor · Oxygen saturation
A,B,D · Explanation: · 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.
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. · Report increased redness and wound drainage to the healthcare provider. · Apply lubricating lotion to the wound bed. · Wash the wound with soap and water. · Remain on bed rest. · Take pain medications daily.
A,C · Explanation: · 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 as instructed; inspect wounds carefully with each dressing change for signs of infection, including increased redness, swelling, drainage, or foul odor; and remain physically active as per therapy.
The nurse cares for a client with extensive burn injuries. Which parameter(s) would the nurse evaluate to determine if the client is receiving adequate fluid resuscitation? Select all that apply. · Heart rate · Oxygen saturation · Blood pressure · Urine output
A,D · Explanation: · Fluid resuscitation is administered to maintain adequate cardiac output and tissue perfusion. If adequate fluid is administered, tachycardia, hypotension, and oliguria will resolve. Expected outcomes of fluid resuscitation specifically include the following: urine output between 0.5 and 1.0 mL/kg/hr (30-50 mL/hr; 75 to 100 mL/hr if electrical burn injury), mean arterial pressure (MAP) pressure > 60 mm Hg, voids clear yellow urine with specific gravity within normal limits, and serum electrolytes are within normal limits.
Which of the following is to be expected soon after a major burn? Select all that apply. · Hypotension · Tachycardia · Anxiety · Hypertension · Bradycardia
AB,C · Explanation: · Tachycardia, slight hypotension, and anxiety are expected soon after the burn.
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: · Epidermal layer only. · Epidermis and a portion of deeper dermis. · Entire dermis and subcutaneous tissue. · Dermis and connective tissue.
B · Explanation: · 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.
A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following? · Superficial · Full-thickness · Superficial partial-thickness · Deep partial-thickness
B · Explanation: · A full-thickness burn involves total destruction of the dermis and extends into the subcutaneous fat. It can also involve muscle and bone. A superficial burn only damages the epidermis. 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.
The palm represents which percentage of a person's TBSA? · 10% · 1% · 15% · 5%
B · Explanation: · 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.
The nurse receives a client following a serious thermal burn. Which complication will the nurse take action to prevent first? · Infection · Hypovolemia · Tissue hypoxia · Renal failure
B · Explanation: · After a burn, fluid from the body moves toward the burned area, which leads to intravascular fluid deficit. Steps must be taken to prevent irreversible hypovolemic shock in the initial stages of treatment. The inflammatory processes that affect the tissues cause additional injury, which contributes to tissue hypoxia. Myoglobin and hemoglobin that were destroyed during the burn can result in acute renal failure. Destruction of the skin barrier results in colonization of bacteria and can lead to life-threatening infection in days following the burn.
The spouse of a client who was struck by lightning asks the nurse why the areas involved seems so small but the damage is extensive. Which is the best explanation from the nurse? · The skin is a good conductor of electricity. · Electrical burns usually follow an internal path. · Lightning is higher in voltage than electricity. · Moisture intensifies the damage inflicted.
B · Explanation: · Electrical current follows the path of less resistance. Because the skin is the most resistant organ, the current follows nerves, blood vessels, and muscles, causing organ damage along the way. Lightning is high-voltage electricity. Presence of water acts as a conductor of electrical current.
A manufacturing plant has exploded, and the nurse is assigned to triage burn victims as they arrive to the hospital. Which is the most important question for the nurse to ask prior to the arrival of victims? · "Are any of the victims expected to have electrical burns?" · "Are the burns associated with chemicals used in the plant?" · "How many victims are anticipated for transport?" · "Are the victims suffering from thermal burns?"
B · Explanation: · If the victim has sustained chemical burns, the chemicals must be removed from the skin to prevent burns to others, including the triage nurse and emergency staff. Thermal and electrical burn victims do not require special handling considerations. The number of victims expected is not a significant issue for the triage nurse but rather for the external disaster team dispatch personnel.
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? · 3 · 1 · 2 · 4
B · Explanation: · 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.
Which of the following is the effect of protein catabolism in a client with severe burns? · It maximizes the risk of sodium retention and hypotension. · It compromises wound healing and immunocompetence. · It compromises dexterity and mobility. · It maximizes the risk of impaired ventilation. · Explanation:
B · Explanation: · Protein catabolism in a client with severe burns compromises wound healing and immunocompetence. Burns of the face, neck, or chest have the potential to impair ventilation, while burns involving the hands or major joints may affect dexterity and mobility. Release of aldosterone, not protein catabolism, causes sodium retention.
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? · The client is alert and conscious. · The client's urinary output is 0.5 to 1 mL/kg/hour. · The client's breathing is unlabored, and skin is clammy. · The client's heart rate is rapid and regular.
B · Explanation: · Successful fluid resuscitation is gauged by a urinary output of 0.5 to 1 mL/kg/hour via an indwelling catheter. Fluid resuscitation does not directly affect the client's heart rate, breathing, or mental status.
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? · 3,600 mL · 2,400 mL · 4,800 mL · 1,200 mL
B · Explanation: · 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.
A young child is being evaluated for an area of burn involvement. The nurse knows the most accurate method of assessing the total body surface area is through the use of which assessment tool? · Rule of nines · Lund and Browder method · Hand method · Parkland formula method
B · Explanation: · The Lund and Browder method divides the body into smaller segments. Different percentages are assigned to body parts, depending on patient's age. For example, the adult head is equivalent to 9%,whereas the infant head is 19%. This method is more accurate when dealing with children. The rule of nines and hand method are quick assessment techniques for estimating burns. The Parkland formula incorporates fluid resuscitation requirements for burns.
A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client? · Anemia · Gastric ulcers · Cardiac arrest · Hyperthyroidism
B · Explanation: · 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.
Which of the following is to be expected soon after a major burn? Select all that apply. · Bradycardia · Tachycardia · Anxiety · Hypotension · Hypertension
B,C,D · Explanation: · Tachycardia, slight hypotension, and anxiety are expected soon after the burn.
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 · Endotracheal tube placement · Prevent infection · Fluid resuscitation · Strict intake and output
C
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? · The client is in hypovolemic shock. · The client has experienced partial-thickness burns. · The client has experienced extensive full-thickness burns. · The paramedic administered high doses of opioids during transport.
C Explanation: 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.
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? · Elevate the extremities above heart level. · Apply warm compresses over the areas. · Instruct to pat and not scratch the areas. · Provide pain medication as needed.
C Explanation: 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.
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? · 9% · 18% · 27% · 36%
C · Explanation: · 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.
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? · 9% · 27% · 36% · 18%
C · Explanation: · 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.
Following a burn injury, the nurse determines which area is the priority for nursing assessment? · Nutrition · Cardiovascular system · Pulmonary system · Pain
C · Explanation: · 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.
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? · Removal of hair · Irrigation of the wound · Application of ice · Removal of clothing
C · Explanation: · 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.
In a client with burns on the legs, which nursing intervention helps prevent contractures? · Elevating the foot of the bed · Hyperextending the client's palms · Applying knee splints · Performing shoulder range-of-motion exercises
C · Explanation: · Applying knee splints is one method which can help prevent leg contractures by holding the joints in a position of function. Elevating the foot of the bed can't prevent contractures because this action doesn't hold the joints in a position of function. Hyperextending a body part for an extended time is inappropriate because it can cause contractures. Performing shoulder range-of-motion exercises can prevent contractures in the shoulders, but not in the legs which is the focus for this individual's treatment and care.
Burn shock is characterized by which of the following? · Organ hyperperfusion · Elevated blood pressure (BP) · Capillary leak · Severe hypervolemia
C · Explanation: · Burn shock is characterized by capillary leak, "third spacing" of fluid, severe hypovolemia, and decreased cardiac output (CO). Progressive edema develops in unburned tissue and organs, causing hypoperfusion and hypovolemic shock. As fluid loss continues and vascular volume decreases, the CO and BP falls. This is the onset of burn shock.
Which zone of burn injury sustains the most damage? · Outer · Protective · Inner · Middle
C · Explanation: · 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.
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 urinary output of 100 mL/hr · A urinary output of 80 mL/hr · A urinary output of 30 mL/hr · A urinary output of 10 mL/hr
C · Explanation: · 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).
When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately? · Urine output of 70 ml the first hour · Moderate to severe pain · Hoarseness of the voice · Complaints of intense thirst
C · Explanation: · 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.
The nurse cares for a client with superficial partial-thickness burn injuries to the lower extremities. The client is ordered IV morphine for pain. The nurse understands narcotics are given via IV during the initial management of pain because · the client can experience nausea and emesis when given oral medications. · bleeding may occur at injection sites when the intramuscular route is used. · tissue edema may interfere with drug absorption via other routes. · pain resulting from a burn injury requires relief by the fastest route available. · Explanation: · IV administration is necessary because of altered tissue perfusion from the burn injury.
C · Explanation: · IV administration is necessary because of altered tissue perfusion from the burn injury.
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? · Age · Weight · Preexisting conditions · Family history
C · Explanation: · 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.
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? · 30% · 18% · 36% · 27%
C · Explanation: · 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.
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? · 9% · 18% · 27% · 36%
D Explanation: 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.
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: · Entire dermis and subcutaneous tissue. · Dermis and connective tissue. · Epidermal layer only. · Epidermis and a portion of deeper dermis.
D · Explanation: · 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.
Which type of burn injury involves destruction of the epidermis and upper layers of the dermis as well as injury to the deeper portions of the dermis? · Full-thickness · Superficial partial thickness · Fourth degree · Deep partial-thickness
D · Explanation: · A deep partial-thickness burn involves destruction of the epidermis and upper layers of the dermis as well as injury to deeper portions of the dermis. In a superficial partial-thickness burn, the epidermis is destroyed or injured and a portion of the dermis may be injured. Capillary refill follows tissue blanching. Hair follicles remain intact. A full-thickness burn involves total destruction of epidermis and dermis and, in some cases, destruction of underlying tissue, muscle, and bone. Although the term fourth-degree burn is not used universally, it occurs with prolonged flame contact or high voltage injury that destroys all layers of the skin and damages tendons and muscles.
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? · 9% · 36% · 18% · 27%
D · Explanation: · 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.
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? · Lie down, have someone cover him with a blanket, and cover his legs with petroleum jelly. · Sit in a chair, elevate his legs, and have someone cut his pants off around the burned area. · Remove his burned pants so that the air can help cool the wound. · Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel. Explanation
D · Explanation: · 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.
Which of the following skin substitutes is a nylon-silicone membrane coated with a protein? · Mederma · Integra · Transcyte · Biobrane
D · Explanation: · 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.
Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is: · Hypoglycemia. · Hypocalcemia. · Hypernatremia. · Hyperkalemia.
D · Explanation: · 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.
A patient will be receiving biologic dressings. The nurse understands that biologic dressings, which use skin from living or recently deceased humans, are known by what name? · Xenografts · Heterografts · Autografts · Homografts
D · Explanation: · Homografts (or allografts) and xenografts (or heterografts) are also referred to as biologic dressings and are intended to be temporary wound coverage. Homografts are skin obtained from recently deceased or living humans other than the patient. Xenografts consist of skin taken from animals (usually pigs). An autograft uses the client's own skin, which is transplanted from one part of the body to another.
A child tips a pot of boiling water onto his bare legs. The mother should: · Avoid touching the burned skin and take the child to the nearest emergency department. · Cover the child's legs with ice cubes secured with a towel. · Immerse the child's legs in cool water. · Liberally apply butter or shortening to the burned areas.
D · Explanation: · 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.
The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to · increase metabolic rate. · increase glucose demands. · increase skeletal muscle breakdown. · decrease catabolism.
D · Explanation: · 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.
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? · The wound is susceptible to infections. · It helps determine the percentage of the total body surface area (TBSA) that is burned. · The client's condition is likely to deteriorate after 72 hours. · The early appearance of the burn injury may change.
D · Explanation: · 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.
Which is the primary reason for placing a client in a horizontal position while smothering flames are present? · To promote blood flow to the brain and vital organs · To prevent collapse and further injuries · To extinguish flames more quickly · To keep fire and smoke from airway
D · Explanation: · 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.
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: · body image. · fluid resuscitation. · infection. · pain management.
D · Explanation: · 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.
