Chapter 62: Burn Injury

Which of the following topical burn preparations act as wick for sodium and potassium? A. Silver nitrate solution B. Silver sulfadiazine (Silvadene) C. Acticoat D. Mafenide acetate (Sulfamylon)

A. Silver nitrate solution Silver nitrate solution is hypotonic and acts as a wick for sodium and potassium. The other preparations do not act as a wick for sodium and potassium.

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. Open a door and encourage air in an enclosed space.' B. Place the client in a vertical position. C. Place the client in a horizontal position. D. Roll the client in a blanket to smother the fire.

C. Place the client in a horizontal position. D. Roll the client in a blanket to smother the fire. If the clothing is on fire, the client is placed in a horizontal position and rolled in a blanket to smother the fire.

Which of the following fluid or electrolyte changes occur in the emergent/resuscitative phase? A. Sodium excess B. Increased urinary output C. Reduction in blood volume D. Potassium deficit

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

The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to A. increase metabolic rate. B. increase skeletal muscle breakdown. C. decrease catabolism. D. increase glucose demands.

C. decrease catabolism. 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 who has been burned significantly is taken by air ambulance to the burn unit. What physiologic process furthers a burn injury? A. intravascular fluid excess B. hypertension C. inflammatory D. neuroendocrine

C. inflammatory The initial burn injury is further extended by inflammatory processes that affect layers of tissue below the initial surface injury.

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 help my burn heal." B. "This medication will stain my skin permanently." C. "This medication is an antibacterial." D. "This medication will be applied directly to the wound."

A. "This medication will help my burn heal." C. "This medication is an antibacterial." D. "This medication will be applied directly to the wound." 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.

A client has been burned significantly in a workplace accident. Which conditions create the need for intensive care by specifically trained personnel? A. All options are correct. B. fluid shift C. fluid loss D. hypotension

A. All options are correct. Fluid shift, fluid loss, and hypotension can lead to irreversible shock. These changes usually happen rapidly and the client's status may change from hour to hour, requiring that clients with burns receive intensive care by skilled personnel.

During the late stages of healing, which intervention helps a burn wound to heal with minimal scarring? A. Applying continuous-compression wraps B. Removing eschar from the skin C. Maintaining wound care irrigation D. Wearing clothing to protect the burn from the sun

A. Applying continuous-compression wraps Applying continuous-compression wraps helps skin healing and prevents hypertrophied tissue from forming. Removing eschar from the skin, wearing clothing to protect the burn from the sun, and maintaining wound care irrigation are appropriate for the client with a burn wound, but these interventions don't necessarily help minimize scarring.

Burn shock is characterized by which of the following? A. Capillary leak B. Organ hyperperfusion C. Elevated blood pressure (BP) D. Severe hypervolemia

A. Capillary leak 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.

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 wait 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.

A. Have someone assist him into a bath of cool water, where he can wait for emergency personnel. 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.

The nurse recognizes that which of the following provide clues about fluid volume status? Select all that apply. A. Skin turgor B. Daily weights C. Oxygen saturation D. Hourly urine output E. Percentage of meals eaten

A. Skin turgor B. Daily weights D. Hourly urine output 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.

The nurse is monitoring for fluid and electrolyte changes in the emergent phase of burn injury for a patient. Which of the following will be an expected outcome? Select all that apply. A. Sodium deficit B. Elevated hematocrit level C. Potassium deficit D. Base-bicarbonate deficit E. Magnesium deficit

A. Sodium deficit B. Elevated hematocrit level D. Base-bicarbonate deficit At the time of burn injury, some red blood cells may be destroyed and others damaged, resulting in anemia. Despite this, the hematocrit may be elevated due to plasma loss. Immediately after burn injury, hyperkalemia (excessive potassium) may result from massive cell destruction. Hyponatremia (serum sodium depletion) may be present as a result of plasma loss. There is a loss of bicarbonate ions accompanying sodium loss, which results in metabolic acidosis (base-bicarbonate deficit).

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. A. Urine output B. Heart rate C. Blood pressure D. Oxygen saturation

A. Urine output B. Heart rate C. Blood pressure 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 limit

Which of the following is a disadvantage of surgical debridement? A. Contractures B. Bleeding C. Loss of Function D. Scarring

B. Bleeding A disadvantage of surgical debridement is bleeding. Scarring, loss of function, and contractures are not disadvantages of surgical debridement.

Which of the following are possible indicators of pulmonary damage from an inhalation injury? Select all that apply. A. Yellow sputum B. Facial burns C. Singed nasal hair D. Bradypnea E. Hoarseness

B. Facial burns C. Singed nasal hair E. Hoarseness Indicators of possible pulmonary damage include singed nasal hair, hoarseness, voice change, stridor, burns of the face or neck, sooty or bloody sputum, and tachypnea.

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

B. Immerse the child's legs in cool water. 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.

A patient has been prescribed Acticoat as a burn wound treatment. Which of the following is accurate regarding application of Acticoat? A. Keep Acticoat saturated. B. Moisten with sterile water only. C. Moisten with saline. D. Use topical antimicrobials with Acticoat burn dressing.

B. Moisten with sterile water only. Acticoat is moistened with sterile water only; never use normal saline. Do not use topical antimicrobials with Acticoat burn dressing. Keep Acticoat moist, not saturated.

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. Can be left in place for 3 to 5 days D. Stains clothing

B. Severe burning pain for up to 20 minutes 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.

Which of the following is to be expected soon after a major burn? Select all that apply. A. Bradycardia B. Tachycardia C. Hypertension D. Anxiety E. Hypotension

B. Tachycardia D. Anxiety E. Hypotension Tachycardia, slight hypotension, and anxiety are expected soon after the burn.

What is an early sign of sepsis in the burn injured client? A. Hypothermia B. Widened pulse pressure C. Clammy skin D. Increased pulse rate

B. Widened pulse pressure The signs of early systemic sepsis are subtle and require a high index of suspicion and very close monitoring of changes in the client's status. Early signs of sepsis may include increased temperature, increased pulse rate, widened pulse pressure, and flushed, dry skin in unburned areas.

A client who was severely burned begins to exhibit symptoms of renal failure during treatment. What physiologic process can cause acute renal failure? A. histamine B. hemoconcentration C. anemia D. fluid, electrolyte status

B. hemoconcentration 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.

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. hyperemia. B. stasis. C. hypotension. D. coagulation.

B. stasis. 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 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 A. pain resulting from a burn injury requires relief by the fastest route available. B. tissue edema may interfere with drug absorption via other routes. C. the client can experience nausea and emesis when given oral medications. D. bleeding may occur at injection sites when the intramuscular route is used.

B. tissue edema may interfere with drug absorption via other routes. IV administration is necessary because of altered tissue perfusion from the burn injury.

A client is scheduled for an allograft to a burn wound, and the client asks for an explanation. What information will the nurse include in the client teaching? A. "An allograft is a permanent wound covering taken from a donor site in your body." B. "An allograft is a temporary wound covering obtained from pig skin." C. "An allograft is a temporary wound covering obtained from cadaver skin." D. "An allograft is an expensive sheet of skin obtained from a culture."

C. "An allograft is a temporary wound covering obtained from cadaver skin." There are several different temporary and permanent coverings for burn wounds. 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 client. Xenografts consist of skin taken from animals (usually pigs). Therefore, the body's immune response will eventually reject them as a foreign substance.

A patient is being discharged after sustaining a deep-partial thickness burn during a house fire. The patient is asking when the burn will be healed. The nurse understands that this type of burn injury heals within which of the following time frames? A. 6 weeks B. 8 weeks C. 2 to 4 weeks D. 1 week

C. 2 to 4 weeks For deep partial-thickness burn injuries, recovery is expected in 2 to 4 weeks.

A client presents to the emergency department following a burn injury. The client has burns to the anterior chest and entire left leg. Using the rule of nines, the nurse documents the total body surface area percentage as A. 9%. B. 18%. C. 36%. D. 27%.

C. 36%. 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%).

A patient is admitted to a burn treatment center at 2:30 p.m. with full-thickness burns over 40% of his body. The injury occurred at 1:30 p.m. at a paper-making plant. The nurse knows that burn shock has to be prevented or treated. Based on fluid volume shifts, the nurse knows that fluid loss would peak by __________ to __________ hours, with the greatest volume being lost from __________ to__________ hours after the burn. A. 10:30 p.m. to 12:30 a.m.; 40 to 50 hours B. 5:30 p.m. to 6:30 p.m.; 9 to 12 hours C. 7:30 p.m. to 9:30 p.m.; 24 to 36 hours D. 4:30 p.m. to 6:30 p.m.; 6 to 8 hours

C. 7:30 p.m. to 9:30 p.m.; 24 to 36 hours The greatest volume of fluid loss occurs in the first 24 to 36 hours after the burn, peaking by 6 to 8 hours.

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? A. Heterografts B. Xenografts C. Homografts D. Autografts

C. Homografts 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.

The open method (exposure method) of burn care, which exposes the burned areas to air, has been virtually abandoned since the advent of effective topical antimicrobials. It is still used on a small scale however. On which areas of the body are burns still being treated this way? Select all that apply. A. The legs B. The chest C. The perineum D. The face

C. The perineum D. The face The open method is still being used with the face and the perineum.

Following a burn, the nurse understands that the focused management of which burn zone is of greatest concern? A. Zone of hyperemia B. Zone in burn center C. Zone of stasis D. Zone of coagulation

C. Zone of stasis The zone of stasis lies outside the burn center and zone of coagulation. This is where the blood vessels are damaged, but tissue has the potential to survive with proper management. The center zone or zone of coagulation is the deepest area of injury and is considered the zone of irreversible damage, placing the focus on saving the surrounding tissues. The zone of hyperemia is the area of least injury.

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. increased skeletal muscle breakdown. B. increased metabolic rate. C. decreased catabolism. D. increased glucose demands.

C. decreased catabolism. 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.

A client has received significant electrical burns in a workplace accident. What occurrence makes it difficult to assess internal burn damage in electrical burns?' A. protein cell coagulation B. continuing inflammatory process C. deep tissue cooling D. All options are correct.

C. deep tissue cooling Because deep tissues cool more slowly than those at the surface, it is difficult initially to determine the extent of internal damage.

During the recovery of an extensive burn, the client is complaining about wearing the tight-fitting custom garment. Which is the best response by the nurse? A. "Perhaps the garment should be resized." B. "The garment can be removed for an hour each day." C. "The garment acts as a skin layer and prevents infection." D. "A snug fit is needed to minimize scarring and overgrowth of skin."

D. "A snug fit is needed to minimize scarring and overgrowth of skin." 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.

To meet early nutritional demands for protein, a 198-lb (90-kg) burned patient will need to ingest a minimum of how much protein every 24 hours? A. 110 g/day B. 90 g/day C. 270 g/day D. 180 g/day

D. 180 g/day (minimum protein requirement should be 2 g/kg)

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. 18% B. 36% C. 9% D. 27%

D. 27% 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 autograft is harvested from a burn client under general anesthesia. What are the disadvantages to harvesting the client's own tissue? Select all that apply. A. There is a potential for donor site infection. B. The donor site has the potential for scarring and atypical pigment changes. C. It compounds the client's pain because it creates a new wound. D. All answers are correct. E. There is a delay in wound closure while waiting for the donor site to heal and be reharvested.

D. All answers are correct. Harvesting a client's own tissue compounds the client's pain because it creates a new wound. The donor site has the potential for scarring and atypical pigment changes. There is a potential for donor site infection. There is a delay in wound closure while waiting for the donor site to heal and be reharvested.

Which of the following is a common complication of an electrical burn injury? A. Localized edema B. Absent bowel sounds C. Loss of mobility D. Cardiac dysrhythmias

D. Cardiac dysrhythmias Cardiac dysrhythmias and central nervous system complications are common among victims of electrical burns; localized edema, absent bowel sounds, and loss of mobility are not.

A nurse provides care for a client with deep partial-thickness burns. What could cause a reduced hematocrit (HCT) in this client? A. Lack of erythropoietin factor B. Metabolic acidosis C. Hemoconcentration D. Hemodilution

D. Hemodilution Reduced HCT is caused by hemodilution, in which volume overload resulting from interstitial-to-plasma fluid shift lowers the concentration of erythrocytes and other blood elements. Hemoconcentration results from hypoalbunimemia, 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 HCT level in this situation. Erythropoietin factor is reduce if kidney failure occurs; however, lack of erythropoietin factor doesn't impact hematocrit level.

Which of the following neuroendocrine changes occur within the first 24 hours of a serious burn? A. Hypoglycemia B. Polyuria C. Sodium loss D. Hyperglycemia

D. Hyperglycemia When the adrenal cortex is stimulated, it releases glucocorticoids , which cause hyperglycemia. Sodium retention leads to peripheral edema. There is a decreased urine output, initially

What is the key sign of onset of acute respiratory distress syndrome? A. Chest pain B. Stridor C. Tachypnea D. Hypoxemia

D. Hypoxemia The key sign of the onset of acute respiratory distress syndrome (ARDS) is hypoxemia while receiving 100% oxygen, with decreased lung compliance and significant shunting. The physician should be notified immediately of deteriorating respiratory status.

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? A. Rule of nines B Hand method C. Parkland formula method D. Lund and Browder method

D. Lund and Browder method 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.

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 prevent collapse and further injuries C. To promote blood flow to the brain and vital organs D. To keep fire and smoke from airway

D. To keep fire and smoke from airway 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. Stop, drop, and roll method is a quick efficient means to distinguish flames. If hypovolemic shock occurs, lowering the head will assist in promoting blood flow to the head.

When the area of burn is irregular in shape and is scattered over multiple areas of the body, which is the best method for the nurse to obtain a quick assessment of the total body surface area of the burn? A. Rule of nines B. Lund and Browder burns assessment C. Parkland formula D. Use client's palm size

D. Use client's palm size A quick assessment technique to use to evaluate an area of burn that is not restricted to one portion of the body is by using the client's palm size to approximate the total body surface. The palm is approximately 1% of a person's TBSA. The Parkland formula determines fluid resuscitation needs. Lund and Browder burns assessment provides a more precise estimate for determining TBSA that is burned and is especially more specific in children. The rule of nines quantitates burns that involve entire sections of the body, not scattered burns.

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. slit graft B. autograft C. xenograft D. allograft

D. allograft 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.

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. silvadene application B. debridement C. allograft D. escharotomy

D. escharotomy 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.

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 charred. What depth of burn injury does the client have? A. superficial (first degree) B. fourth degree C. superficial partial-thickness or deep partial-thickness (second degree) D. full thickness (third degree)

D. full thickness (third degree) Full-thickness (third degree) burn destroys all layers of the skin and consequently is painless. The tissue appears 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.

A nurse is caring for a client with skin grafts covering full-thickness burns on the arms and legs. During dressing changes, the nurse should: A. remove bandages with clean gloves. B. apply maximum bandages to allow for absorption of drainage. C. wrap elastic bandages on the arms and legs, proximally to distally, to promote venous return. D. wrap elastic bandages distally to proximally on dependent areas.

D. wrap elastic bandages distally to proximally on dependent areas. Wrapping elastic bandages on dependent areas limits edema formation and bleeding and promotes graft acceptance. The nurse should wrap the client's arms and legs from the distal to proximal ends and use strict sterile technique throughout the dressing change. The nurse shouldn't use maximum bandages because bulky dressings limit mobility; instead, the nurse should use enough bandages to absorb wound drainage. Sterile gloves are required throughout all phases of the dressing change to prevent contamination.

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 30 mL/hr B. A urinary output of 10 mL/hr C. A urinary output of 100 mL/hr D. A urinary output of 80 mL/hr

A. A urinary output of 30 mL/hr 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).

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. Application of ice B. Removal of hair C. Removal of clothing D. Irrigation of the wound

A. Application of ice 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? A. Applying knee splints B. Elevating the foot of the bed C. Hyperextending the client's palms D. Performing shoulder range-of-motion exercises

A. Applying knee splints Applying knee splints prevents 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.

The nurse in the emergency department receives a patient who sustained a severe burn injury. What is the priority action by the nurse in this situation? A. Establish a patent airway. B. Insert an indwelling catheter. C. Replace fluids. D. Administer pain medication.

A. Establish a patent airway. Nursing assessment in the emergent phase of burn injury focuses on the major priorities for any trauma patient; the burn wound is a secondary consideration to stabilization of airway, breathing, and circulation.

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

A. Hoarseness of the voice 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.

Which zone of burn injury sustains the most damage? A. Inner B. Middle C. Protective D. Outer

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

Which type of debridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar? A. Mechanical B. Natural C. Chemical D. Surgical

A. Mechanical Mechanical debridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar. Topical enzymatic debridement agents are available to promote debridement of the burn wounds. With natural debridement, the dead tissue separates from the underlying viable tissue spontaneously. Surgical debridement is an operative procedure involving either primary excision (surgical removal of tissue) of the full thickness of the skin down to the fascia (tangential excision) or shaving of the burned skin layers gradually down to freely bleeding, viable tissue.

Which of the following is the analgesic of choice for burn pain? A. Morphine sulfate B. Fentanyl C. Tylenol with codeine D. Demerol

A. Morphine sulfate Morphine sulfate remains the analgesic of choice. It is titrated to obtain pain relief on the patient's self-report of pain. Fentanyl is particularly useful for procedural pain, because it has a rapid onset, high potency, and short duration, all of which make it effective for use with procedures. Demerol and Tylenol with codeine are not analgesics of choice for burn pain.

The nurse cares for a 30-year-old client who suffered severe head and facial burn injuries. Which action, if completed by the client, indicates the client is adapting to altered body image? Select all that apply. A. Participates actively in daily activities B. Reports absence of sleep disturbance C. Covers face with a scarf D. Wears hats and wigs

A. Participates actively in daily activities D. Wears hats and wigs The following are indicators that a client is adapting to altered body image: verbalizes accurate description of alterations in body image and accepts physical appearance, demonstrates interest in resources that may improve function and perception of body appearance (e.g., uses cosmetics, wigs, and prostheses, as appropriate); socializes with significant others, peers, and usual social group; and seeks and achieves return to role in family, school, and community as a contributing member. Covering the face with a scarf indicates the client is not adapting to the alteration in body image; absence of sleep disturbances is expected by the burn-injured client but is not related to body image disturbance.

Following a burn injury, the nurse determines which area is the priority for nursing assessment? A. Pulmonary system B. Nutrition C. Pain D. Cardiovascular system

A. Pulmonary system 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.

The nurse participates in a health fair about fire safety. When clothes catch fire, which intervention helps to minimize the risk of further injury to an affected person at a scene of a fire? A. Roll the client in a blanket. B. Avoid immediate IV fluid therapy. C. Cover the client with a wet cloth. D. Place the client with the head positioned slightly below the rest of the body.

A. Roll the client in a blanket. When clothing catches fire, the flames can be extinguished if the person drops to the floor or ground and rolls ("stop, drop, and roll"); anything available to smother the flames, such as a blanket, rug, or coat, may be used. The older adult, or others with impaired mobility, could be instructed to "stop, sit, and pat" to prevent concomitant musculoskeletal injuries. 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.

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. Ligaments, tendons, muscles, and bone are not involved. C. The wound will take up to 3 weeks to heal. D. Pain management will be a challenge.

A. Skin grafting will be necessary. 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

What are the expected findings in the fluid remobilization phase (acute phase, diuresis) that the nurse should monitor for? Select all that apply. A. Sodium deficit B. Hypoglycemia C. Increased urinary output D. Hemodilution E. Metabolic alkalosis

A. Sodium deficit C. Increased urinary output D. Hemodilution Hemodilution (decreased hematocrit), increased urinary output, metabolic acidosis (not alkalosis), sodium deficit, and hypokalemia (not hypoglycemia) are typical fluid and electrolyte changes that occur in the acute phase (fluid remobilization phase, state of diuresis).

Which of the following is a potential cause of a superficial partial-thickness burn? A. Sunburn B. Electrical current C. Scald D. Flash flame

A. Sunburn 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.

As the first priority of care, a patient with a burn injury will initially need: A. a patent airway established. B. an indwelling catheter inserted. C. pain medication administered. D. fluids replaced.

A. a patent airway established. Breathing must be assessed and a patent airway established immediately during the initial minutes of emergency care. Immediate therapy is directed toward establishing an airway and administering humidified 100% oxygen.

Which complication is common for victims of electrical burns? A. Inhalation injury B. Cardiac dysrhythmia C. Hypovolemic shock D. Infection

B. Cardiac dysrhythmia 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 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. Broken epidermis that is weeping. B. Dry and pale white. C. Blistered with a mottled red base. D. Reddened; blanches with pressure.

B. Dry and pale white. The wound appearance for a full-thickness burn would be dry, pale white, leathery, or charred. Refer to Table 53-1 in the text.

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? A. Moisture intensifies the damage inflicted. B. Electrical burns usually follow an internal path. C. The skin is a good conductor of electricity. D. Lightning is higher in voltage than electricity.

B. Electrical burns usually follow an internal path. Electrical current follows the path of less resistance. Becausethe 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.

Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is: A. Hypocalcemia. B. Hyperkalemia. C. Hypernatremia. D. Hypoglycemia.

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

B. Irrigate the wounds with water. 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.

Which of the following is the effect of protein catabolism in a client with severe burns? A. It maximizes the risk of sodium retention and hypotension. B. It compromises wound healing and immunocompetence. C. It maximizes the risk of impaired ventilation. D. It compromises dexterity and mobility.

B. It compromises wound healing and immunocompetence. 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.

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. Age B. Preexisting conditions C. Family history D. Weight

B. Preexisting conditions 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 nurse is aware that after a burn injury and respiratory difficulties have been managed, the next most urgent need is to: A. Prevent renal shutdown. B. Replace lost fluids and electrolytes. C. Monitor cardiac status. D. Measure hourly urinary output.

B. Replace lost fluids and electrolytes 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.

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. Alteration in Tissue Perfusion B. Risk for Impaired Gas Exchange C. Acute Pain D. Risk for Infection

B. Risk for Impaired Gas Exchange 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.

The nurse knows that which topical antibacterial agent does not penetrate eschar? A. Acticoat B. Silver nitrate 0.5% C. Mafenide acetate D. Silver sulfadiazine 1%

B. Silver nitrate 0.5% Silver nitrate 0.5% does not penetrate eschar.

Which type of burn is similar to a sunburn? A. Electrical B. Superficial partial-thickness C. Deep partial-thickness D. Full-thickness

B. Superficial partial-thickness A superficial partial-thickness burn is similar to a sunburn. Deep partial thickness burns may need debridement and may scar. Full-thickness burns destroy all layers of the skin and consequently are painless. Electrical burns are a type of burn but not a category of burn thickness.

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? A. Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg B. Urine output of 20 ml/hour C. Rectal temperature of 100.6° F (38° C) D. White pulmonary secretions

B. Urine output of 20 ml/hour 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.

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? A. Fourth degree B. Superficial partial thickness C. Deep partial-thickness D. Full-thickness

C. Deep partial-thickness 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.

The nurse is caring for a patient who sustained a full-thickness burn to his arm when he was scalded with boiling water. How did the nurse determine that the patient's burns are full-thickness burns? A. Not associated with edema formation B. Usually very painful because of exposed nerve endings C. Identification by the destruction of the dermis and epidermis D. Classification by the appearance of blisters

C. Identification by the destruction of the dermis and epidermis Third-degree (full-thickness) burns involve total destruction of the epidermis and dermis and, in some cases, destruction of underlying tissue. Second-degree burns are associated with blister formation.

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. Music therapy may provide reality orientation, distraction, and sensory stimulation. D. Pet therapy has proven effective in the management of burn pain.

C. Music therapy may provide reality orientation, distraction, and sensory stimulation. 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.

Which of the following would indicate the need to increase fluids beyond what is recommended for fluid resuscitation? A. Increase in antidiuretic hormone (ADH) B. Elevation of blood glucose levels C. Myoglobin in the urine D. Hypernatremia

C. Myoglobin in the urine 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.

After being exposed to smoke and flames from a house fire, which assessment finding is most important in determining care of the client? A. Partial-thickness burns to hands and wrists B. Elevation of blood pressure and heart rate C. Presence of soot around nasal passages D. Fracture of the fibula with displacement

C. Presence of soot around nasal passages If the client has soot or evidence of carbon about the nasal passages, the nurse should anticipate respiratory difficulties. Edema and swelling of the internal airways may not be present initially but can progress quickly. Elevation of heart rate without hypotension is not as significant. Fracture to any bone as well as care of burns should be managed once the airway, breathing, and circulation are assessed and managed.

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 has experienced partial-thickness burns. B. The client is in hypovolemic shock. C. The client has experienced extensive full-thickness burns. D. The paramedic administered high doses of opioids during transport.

C. The client has experienced extensive full-thickness burns. 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 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 exhibits metabolic alkalosis. C. The client's complete blood count readings reflect a reduced hematocrit. D. The client's serum sodium levels are elevated.

C. The client's complete blood count readings reflect a reduced hematocrit. 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.

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. fluid resuscitation. B. infection. C. pain management. D. body image.

C. pain management. 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.

A client with a burn wound is prescribed mafenide acetate 5% twice daily. Nursing implications associated with this medication include A. monitoring the client for the development of respiratory acidosis. B. monitoring the client's Na+ and K+ serum levels and replace as prescribed. C. premedicating the client with an analgesic prior to application. D. protecting the bed linens and client's clothing from contact to prevent staining.

C. premedicating the client with an analgesic prior to application. 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 antimicrobials is not commonly used to treat burns? A. mafenide (Sulfamylon) B. silver nitrate (AgNO3) 0.5% solution C. tetracycline D. silver sulfadiazine (Silvadene)

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

The nurse has completed teaching home care instructions to a client being discharged from the burn unit. Which statement from the client indicates the need for further teaching? A. "I can work with the social worker to find funding assistance programs to help with my medical expenses." B. "I will wear sun block with the highest SPF possible to protect exposed burned skin from the sun." C. "I will drink a lot of fluids to prevent constipation since I am taking pain medications." D. "As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help."

D. "As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help." Itching is a normal part of healing. Many clients describe this as one of the most uncomfortable aspects of burn recovery. The client can apply mild moisturizers to decrease itching from dryness. Medications can be discussed with your treatment team. The client should pat the areas; scratching is contraindicated. The other statements indicate that teaching has been effective.

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

D. A urine output consistently above 40 ml/hour 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.

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. Insert a urinary Foley catheter B. Obtain a 12-lead ECG C. Take the client's vital signs D. Apply a cervical collar on the client

D. Apply a cervical collar on the client 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.

Which type of graft utilizes the client's own skin for wound coverage? A. Slit graft B. Allograft C. Heterograft D. Autograft

D. Autograft An autograft uses the client's own skin, which is transplanted from one part of the body to another. A heterograft is obtained from animals, principally pigs. An allograft is human skin obtained from a cadaver. A slit graft is used when the area available as a donor site is limited, as in clients with extensive burns.

During the acute phase of burn injury, the nurse knows to assess for signs of potassium shifting during what time frame? A. Between 24 and 48 hours B. Within 24 hours C. At the beginning of the third day D. Beginning on day 4 or day 5

D. Beginning on day 4 or day 5 Beginning on the fourth or fifth post-burn day, potassium ions shift from the extracellular fluid into cells, leading to a potassium deficit.

Which of the following skin substitutes is a nylon-silicone membrane coated with a protein? A. Mederma B. Transcyte C. Integra D. Biobrane

D. Biobrane Biobrane is a nylon-silicone membrane coated with a protein. Mederma ia 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.

Which zone consists of the area where the injury is most severe and deepest? A. Stasis B. Hyperemia C. Necrosis D. Coagulation

D. Coagulation The zone of coagulation is at the center of the injury and is the area of injury that is most severe and the deepest. The zone of stasis is the area of intermediate burn injury. The zone of hyperemia is the area of least injury, where the epidermis and dermis are only minimally damaged. There is no zone of necrosis.

The nurse provides care for a client with a full-thickness, circumferential burn of the left lower leg. During the nurse's initial shift assessment, the client is resting and the physical assessment of the left lower extremity is unremarkable. One hour later, the nurse notes the pulses of the left lower leg cannot be obtained by a Doppler ultrasound device, and the capillary refill of the left great toe is greater than 2 seconds. What is the nurse's best response based on the clinical findings? A. Document the findings and instruct the client to report numbness of the extremity. B. Apply an elastic stocking to the extremity and administer SQ heparin per order. C. Elevate the leg on pillows and reassess the leg in 1 hour. D. Contact the primary care provider and prepare for an escharotomy.

D. Contact the primary care provider and prepare for an escharotomy. The nurse assesses peripheral pulses frequently with a Doppler ultrasound device, if needed. Frequent assessment also includes warmth, capillary refill, sensation, and movement of extremity. It is necessary for the nurse to report loss of pulse or sensation or presence of pain to the physician immediately and to prepare to assist with an escharotomy. The other interventions are inappropriate when the nurse has detected a loss of peripheral pulses.

A nurse knows to assess a patient with a burn injury for gastrointestinal complications. Which of the following is a sign that indicates the presence of a paralytic ileus? A. Hematemesis B. Hyperactive bowel sounds C. Fecal occult blood D. Decreased peristalsis

D. Decreased peristalsis Decreased peristalsis and hypoactive bowel sounds are manifestations of a paralytic ileus.

A client presents with a full-thickness burn to the anterior chest. The leathery skin is tight, making breathing difficult. The nurse anticipates which treatment management technique in the care of this client? A. Ventilator assisted breathing B. Endotracheal tube insertion C. Tracheostomy D. Escharotomy

D. Escharotomy In areas of full-thickness burns, eschar constricts the area and can impair circulation or expansion of the anterior chest wall. An escharotomy is performed to release the burn tissue on the anterior chest, freeing the chest for expansion with inspiration. Endotracheal tube insertion, tracheostomy, and ventilation do not correct the tightening of the chest and poor expansion issue.

The nurse is caring for a patient 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 immediately when reviewing laboratory studies? A. Hypernatremia B. Hypokalemia C. Hypercalcemia D. Hyperkalemia

D. Hyperkalemia 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.

Which of the following types of shock will a nurse observe in a client with extensive burns? A. Anaphylactic shock B. Neurogenic shock C. Septic shock D. Hypovolemic shock

D. Hypovolemic shock Clients with extensive burns may exhibit hypovolemic shock due to the loss of blood or plasma. Clients with extensive burns are unlikely to display the symptoms of anaphylactic, neurogenic, or septic shock.

The nurse is administering an analgesic to a patient with major burns. What is the recommended route for administration for this patient? A. Oral B. Intramuscular C. Subcutaneous D. Intravenous

D. Intravenous Intravenous administration is necessary because of altered tissue perfusion from burn injury.

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. Albumin C. Normal saline solution with 20 mEq of potassium per 1,000 ml D. Lactated Ringer's solution

D. Lactated Ringer's solution 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.

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. Cerium nitrate solution B. Gentamicin sulfate C. Mafenide (Sulfamylon) D. Sulfadiazine, silver (Silvadene)

D. Sulfadiazine, silver (Silvadene) 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.)

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 is alert and conscious. B. The client's heart rate is rapid and regular. C. The client's breathing is unlabored, and skin is clammy. D. The client's urinary output is 0.3 to 0.5 mL/kg/hour.

D. The client's urinary output is 0.3 to 0.5 mL/kg/hour. Successful fluid resuscitation is gauged by a urinary output of 0.3 to 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 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 is conscious. C. The client's breathing is unlabored and skin is clammy. D. The client's urinary output is 0.5 mL/kg/hour.

D. The client's urinary output is 0.5 mL/kg/hour. 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 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? A. "Are the burns associated with chemicals used in the plant?" B. "Are the victims suffering from thermal burns?" C. "How many victims are anticipated for transport?" D. "Are any of the victims expected to have electrical burns?"

A. "Are the burns associated with chemicals used in the plant?" 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.

Which is a quick technique to assess the percentage of a burn injury? A. comparing the client's palm with the size of the burn wound B. observing the color of the client's wound C. observing the client's level of consciousness D. checking the client's vital signs

A. comparing the client's palm with the size of the burn wound A quick technique to assess the percentage of burn injury is to compare the client's palm with the size of the burn wound. The palm is approximately 1% of a person's TBSA.

A nurse is developing a care plan for a client recovering from a serious thermal burn. After maintaining respirations, the nurse knows that the most important immediate goal of therapy is: A. maintaining the client's fluid, electrolyte, and acid-base balance. B. planning for the client's rehabilitation and discharge. C. preserving full range of motion in all affected joints. D. providing emotional support to the client and family.

A. maintaining the client's fluid, electrolyte, and acid-base balance After maintaining respirations, the most important immediate goal of therapy for a client with a serious thermal burn is to maintain fluid, electrolyte, and acid-base balance to avoid potentially life-threatening complications, such as shock, disseminated intravascular coagulation, respiratory failure, cardiac failure, and acute tubular necrosis. Planning for the client's rehabilitation and discharge, providing emotional support, and preserving full range of motion in all affected joints are important aspects of care but don't take precedence over maintaining the client's fluid, electrolyte, and acid-base balance.

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

B. 1 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 clients's palm, including the surface area of the digits, is approximately 1% of the total body surface area.

A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned? A. 18% B. 27% C. 36% D. 45%

B. 27% The TBSA would be 27%. 18% for the anterior trunk and 9% for the left arm.

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. 9% D. 27%

B. 36% 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 thathave sustained burns to entire surfaces will equal to 36% of total surface area.

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. Application of cool water 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.

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. Ca: 9 mg/dL B. BUN: 28 mg/dL C. Na+: 145 mEq/L D. K+: 5.0 mEq/L

B. BUN: 28 mg/dL 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.

Which is the primary nursing intervention in the care of a client with burns exceeding 20% of total body surface area? A. Prevent infection B. Fluid resuscitation C. Endotracheal tube placement D. Strict intake and output

B. Fluid resuscitation 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.

During the acute phase of a burn, a nurse should assess: A. tobacco use. B. circulatory status. C. the client's lifestyle. D. alcohol use.

B. circulatory status. 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.

Specific potential complications are common to specific types of burns. Which burns can impair ventilation? A. perineal B. face, neck, chest C. hands, major joints D. All options are correct.

B. face, neck, chest Burns of the face, neck, or chest have the potential to impair ventilation.

A sample consensus formula for fluid replacement recommends that an isotonic solution be administered in the first 24 hours of a burn in the range of 2 to 4 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. 4,800 mL B. 3,600 mL C. 2,400 mL D. 1,200 mL

C. 2,400 mL The minimum replacement is 2 mL/kg/%. Therefore, 2 mL × 80 kg = 160 mL × 30% = 4,800 mL. To give 50% in the first 8 hours, the nurse would give 2,400 mL.

Acticoat antimicrobial barrier dressings used in the treatment of burn wounds can be left in place for which time frame? A. 2 days B. 3 days C. 5 days D. 7 to 10 days

C. 5 days Acticoat antimicrobial barrier dressings can be left in place for up to 5 days thus helping to decrease discomfort to the client, decrease costs of dressing supplies, and decrease nursing time involved in burn dressing changes.

What quick assessment technique should the nurse use to assess the percentage of burn injury? A. Check the client's vital signs B. Observe the color of the client's wound C. Compare the client's palm with the size of the burn wound D. Observe the client's level of consciousness

C. Compare the client's palm with the size of the burn wound A quick technique to assess the percentage of burn injury is to compare the client's palm with the size of the burn wound. The palm is approximately 1% of a person's total body surface area. Observing the color of the client's wound, checking the client's vital signs, and observing the client's level of consciousness determine the client's health status but do not help assess the percentage of burn injury.

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. Epidermal layer only. B. Entire dermis and subcutaneous tissue. C. Epidermis and a portion of deeper dermis. D. Dermis and connective tissue.

C. Epidermis and a portion of deeper dermis. 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? A. Superficial partial-thickness B. Deep partial-thickness C. Full-thickness D. Superficial

C. Full-thickness 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 froma full-thickness burn. It is red or white, mottled, and can be moist or fairly dry.

Skin grafts are necessary for which of the following burns? A. Superficial B. Superficial partial thickness C. Full-thickness D. First degree

C. Full-thickness Skin grafts are necessary for a full-thickness burn because the skin cells no longer are alive to regenerate. Superficial (first degree), superficial partial-thickness burns do not usually need skin grafting.

A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client? A. Anemia B. Cardiac arrest C. Gastric ulcers D. Hyperthyroidism

C. Gastric ulcers 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.

Following a serious thermal burn, which complication will the nurse take action to prevent first? A. Infection B. Renal failure C. Hypovolemia D. Tissue hypoxia

C. Hypovolemia 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.

When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority? A. Risk for infection related to breaks in the skin B. Impaired physical mobility related to the disease process C. Ineffective airway clearance related to edema of the respiratory passages D. Disturbed sleep pattern related to facility environment

C. Ineffective airway clearance related to edema of the respiratory passages When caring for a client with upper torso burns, the nurse's primary goal is to maintain respiratory integrity. Therefore, Ineffective airway clearance related to edema of the respiratory passages should take the highest priority. Impaired physical mobility related to the disease process isn't appropriate because burns aren't a disease. Disturbed sleep pattern related to facility environment and Risk for infection related to breaks in the skin may be appropriate, but they don't command a higher priority than Ineffective airway clearance because they don't reflect immediately life-threatening problems.

Which of the following is the preferred IV fluid for burn resuscitation? A. D5W B. Total parenteral nutrition (TPN) C. Lactated Ringer's (LR) D. Normal saline (NS)

C. Lactated Ringer's (LR) LR is the preferred IV fluid for burn resuscitation because the sodium concentration and potassium are similar to normal intravascular levels. NS, D5W, and TPN are not the IV of choice for burn resuscitation.

In a client who has been burned, which medication should the nurse expect to use to prevent infection? A. Meperidine (Demerol) B. Lindane (Kwell) C. Mafenide (Sulfamylon) D. Diazepam (Valium)

C. Mafenide (Sulfamylon) The topical antibiotic mafenide is ordered to prevent infection in clients with partial-thickness and full-thickness burns. Lindane is a pediculicide used to treat lice infestation. Diazepam is an antianxiety agent that may be administered to clients with burns, but not to prevent infection. The opioid analgesic meperidine is used to help control pain in clients with burns.

Which type of debridement occurs when nonliving tissue sloughs away from uninjured tissues? A. Surgical B. Mechanical C. Natural D. Enzymatic

C. Natural 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.

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. Face, neck, and chest B. Face only C. Neck and chest D. Face and neck

C. Neck and chest 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.

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. Ulcerative colitis C. Paralytic ileus D. Hematemesis

C. Paralytic ileus 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.

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

C. The early appearance of the burn injury may change. 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.

When using the Palmer method to estimate the extent of the burn injury, the nurse determines the palm is equal to which percentage of total body surface area? A. 4 B. 2 C. 3 D. 1

D. 1 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.

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 24 hours after surgery B. Within 12 hours after surgery C. As soon as sanguineous drainage is noted D. 2 to 5 days after surgery

D. 2 to 5 days after surgery 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.

The nurse cares for a client in the burn unit. What is an early sign of sepsis in the client with burn injury? A. Hyperthermia B. Clammy skin C. Decreased pulse rate D. Narrowing pulse pressure

D. Narrowing pulse pressure Clienst with burns are hypermetabolic. This results in tachycardia, tachypnea, and elevated body temperature. These physiological norms in clients with burns make the diagnosis of sepsis more challenging. The signs of early systemic sepsis are subtle and require a high index of suspicion and very close monitoring of changes in the client's status. Early signs of sepsis may include increased temperature, increased pulse rate, widened pulse pressure, and flushed, dry skin in unburned areas.

Which instruction is the most important to give a client who has recently had a skin graft? A. Continue physical therapy. B. Apply lubricating lotion to the graft site. C. Use cosmetic camouflage techniques. D. Protect the graft from direct sunlight.

D. Protect the graft from direct sunlight. To prevent burning and sloughing, the nurse must instruct the client to protect the graft from direct sunlight. Continuing physical therapy, using cosmetic camouflage techniques, and applying lotion to the graft site are appropriate instructions, but they aren't the most important concern in the client's recovery.

Which of the following is a true statement regarding the purposes of skin grafts? A. Increases potential for infection. B. Increases evaporative fluid loss. C. Prolongs recovery D. Reduces scarring and contractures.

D. Reduces scarring and contractures Purposes of a skin graft include the reduction of scarring and contractures, to decrease evaporative fluid loss, decrease the potential for infection, and speed recovery.

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 femoral artery occlusion B. Related to fat emboli C. Related to infection D. Related to circumferential eschar

D. Related to circumferential eschar 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.

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: A. increase edema in the arms. B. decrease circulation to the fingers. C. increase the amount of scarring. D. dislodge the autografts.

D. dislodge the autografts. 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.

Which of the following site is the source of most microbes leading to bacterial infection? A. Intestinal tract B. Respiratory tract C. Skin D. Mucous membranes

A. Intestinal tract When the wound is healing, it must be protected from infection. A primary source of bacterial infection is the patient's intestinal tract, the source of most microbes. The respiratory tract, skin, and mucous membranes are not the source of most microbes.

The nurse understands that during the emergent/resuscitative phase of burn injury, hemoconcentration is due to which of the following? A. Liquid blood component is lost into extravascular space B. Fluid loss C. Decreased renal blood flow D. Sodium and water retention caused by increase adrenocortical activity

A. Liquid blood component is lost into extravascular space Hemoconcentration is due to the blood component being lost into the extravascular space. Decreased urinary output occurs secondary to fluid loss, decreased renal blood flow, and sodium and water retention caused by increased adrenocortical activity.

The palm represents which percentage of a person's TBSA? A. 1% B. 10% C. 15% D. 5%

A. 1% 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.

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. 30% C. 18% D. 27%

A. 36% 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.

Which type of burn injury requires skin grafting? A. Full-thickness B. Deep partial-thickness C. Superficial D. Superficial partial-thickness

A. Full-thickness 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.

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. Full-thickness B. Deep partial-thickness C. Superficial D. Superficial partial-thickness

C. Superficial 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.