CHAPTER 66

A client, who has sustained burns to the anterior chest and upper extremities, is brought to the burn center. During the initial stage of assessment, which nursing diagnosis is primary? A)Risk for Impaired Gas Exchange B)Acute Pain C)Risk for Infection D)Alteration in Tissue Perfusion

A

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

A

One major antimicrobial used in the treatment of burns is silver sulfadiazine (Silvadene) ointment. When providing instructions for the use of silver sulfadiazine (Silvadene), which teaching measure should be stressed? A)Cleanse skin prior to application. B)Apply dressing over ointment. C)Apply moderate amounts to burn area. D)Do not apply to newly debrided areas.

A

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

A

Which of the following actions should a nurse perform to help reduce the accumulation of debris within the burn wound? A)Use powder-free sterile gloves. B)Use topical antimicrobial medications. C)Use cold compresses or sponges. D)Use sterilized gauze swaps.

A

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

A

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

A

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)Gastric ulcers C)Hyperthyroidism D)Cardiac arrest

B

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

B

A young child is being evaluated for 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)Lund and Browder method C)Hand method D)Parkland formula method

B

An explosion of a fuel tanker has resulted in melting of clothing on the driver and extensive full-body burns. The client is brought into the emergency department alert, denying pain, and joking with the staff. Which is the best interpretation of this behavior? A)The client is in hypovolemic shock. B)The client has experienced extensive full-thickness burns. C)The paramedic administered high doses of opioids during transport. D)The client has experienced partial-thickness burns.

B

Following a burn to a large area of the body, the client receives an Oasis porcine graft. Which statement by the client indicates an understanding of the use of this grafting material? A)"This graft contains material obtained from a cow." B)"This graft will not become a permanent part of my skin." C)"This graft was applied with a spray gun." D)"This graft was harvested from another human."

B

When providing initial assessment to a client who has suffered an electrical burn, which assessment finding will provide the most important data? A)Size of burn B)Location of entry and exit wounds C)Level of pain D)Amount of fluid replaced

B

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)Use client's palm size C)Parkland formula D)Lund and Browder burns assessment

B

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

Which is the primary reason for placing a client in a horizontal position while smothering flames are present? A)To prevent collapse and further injuries B)To keep fire and smoke from airway C)To distinguish flames more quickly D)To promote blood flow to the brain and vital organs

B

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

B

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

B

Which type of skin graft is more comparable in appearance to normal skin? A)Lace graft B)Full-thickness graft C)Slit graft D)Split-thickness graft

B

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)Endotracheal tube insertion B)Tracheostomy C)Escharotomy D)Ventilator assisted breathing

C

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 victims suffering from thermal burns?" B)"How many victims are anticipated for transport?" C)"Are the burns associated with chemicals used in the plant?" D)"Are any of the victims expected to have electrical burns?"

C

A nurse is required to care for a client with facial burns who is prescribed the open method treatment. Which of the following nursing interventions should a nurse perform? A)Administer a cold sponge bath to the client. B)Keep the client's room cool and airy. C)Place a bed cradle or sheets over the client. D)Place the client on a moist linen sheet.

C

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 acts as a skin layer and prevents infection." C)"A snug fit is needed to minimize scarring and overgrowth of skin." D)"The garment can be removed for an hour each day."

C

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

C

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

C

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

C

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)Weight C)Preexisting conditions D)Family history

C

Skin substitutes are often used after the wound is debrided and cleaned. Which of the following supports a primary purpose for the use of a skin substitute? Select all that apply. A)Lessen potential for infection B)Maximizes fluid loss C)Promotes granulation of tissue D)Covers the unattractiveness of the wound E)Slows regeneration of tissue F)Diminishes pain

A,F

Which of the following are benefits that support the use of a closed method wound care in the management of a client with burns? Select all that apply. A)Provides a drier environment B)Promotes heat loss C)Creates antimicrobial barrier D)Prevents exudate accumulation E)Discourages hypertrophic scarring F)Promotes slower healing

C,E

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

D

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

D

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

D

The nurse is providing education to the client with multiple burns and lists the options for skin grafting and application techniques. Which is the primary benefit for using an autograft slit graft versus other types of grafts? A)Less scarring B)Less discomfort C)Speeds healing D)Rejection is unlikely.

D

Which of the following skin substitutes is a nylon-silicone membrane coated with a protein derived from pig tissue? A)Mederma B)Integra C)TransCyte D)Biobrane

D