EAQ N4510 Burns Summer 2020

A 5-year-old child is admitted with burns covering the face and anterior arms and hands. Using the total body surface area (TBSA) percentages shown in the diagram, determine what percentage of the child's body has been burned. Record your answer using a whole number. ____%

15% Rationale: The front of a 5-year-old's head accounts for 6.5% of the TBSA. The anterior portion of each arm and hand accounts for 4.25% of the TBSA. Adding 6.5 + 4.25 + 4.25 = 15.

A nurse is using the rule of nines to estimate burn injury in a client. The client has burns on the front chest, front abdomen, both sides of both upper extremities, and entire head. Calculate the percentage of body surface burned. Record your answer as a whole number. ______%

45% Rationale: The chest is 9%, the front abdomen is 9%, each upper extremity is 9% (for a total of 18% for both), and the entire head and neck are 9%. 9 + 9 + 18 + 9 = 45.

Which gastrointestinal (GI) change may be found in the client with burn injuries? A. Abdominal distention B. Increased peristalsis C. Activation of GI motility D. Increased blood flow to the GI area

A. Abdominal distention Rationale: The client with burn injuries may have abdominal distention due to loss of peristalsis. Gastrointestinal motility may be inhibited with burn injuries. Blood flow may be reduced and mucosal damage might have occurred.

While caring for a client with a burn injury and in the resuscitation phase, the nurse notices that the client is hoarse and produces audible breath sound on exhalation. Which immediate action would be appropriate for the safe care of the client? Select all that apply. A. Providing oxygen immediately B. Notifying the rapid response team C. Considering it a normal observation D. Initiating an intravenous (IV) line and beginning fluid replacement E. Obtaining an electrocardiogram (ECG) of the client

A. Providing oxygen immediately B. Notifying the rapid response team Rationale: Hoarseness of voice, difficulty in swallowing, or an audible breath sound on exhalation after a burn injury indicates an impaired airway. Therefore the client should be given oxygen immediately. The rapid response team should also be notified for further management. This occurrence should not be considered a normal observation. An IV line should be initiated for fluid replacement only once the client's airway is patent. An ECG is obtained when the client suffers from electrical burns.

The registered nurse has instructed the client about effective ways of reducing burn injury. Which statement made by the client shows ineffective learning? A. "I will refrain from smoking when lying in bed." B. "I will set the bathing water temperature below 160° F." C. "I will use a potholder when taking the food from an oven." D. "I will keep the screens and doors closed on the front of any fireplace."

B. "I will set the bathing water temperature below 160°F." Rationale: The water tank should be set below 140° F; higher temperatures may result in scald burns. Smoking in bed should be avoided to prevent injury due to fire. Potholders should be used while taking food from the oven to prevent thermal burn injuries. For preventing flame burn injuries, the screens and the doors should be kept closed on the front of fireplaces.

A client is rescued from a house fire and arrives at the emergency department 1 hour after the rescue. The client weighs 132 pounds (60 kilograms) and is burned over 35% of the body. The nurse expects that the amount of lactated Ringer solution that will be prescribed to be infused in the next 8 hours is what? A. 2100 mL B. 4200 mL C. 6300 mL D. 8400 mL

B. 4200 mL Rationale: In the first 8 hours 4200 mL should be infused. According to the Parkland (Baxter) formula, one half of the total daily amount of fluid should be administered in the first 8 hours. Because the client weighs 60 kg (132 pounds ÷ 2.2 kg = 60 kg), the calculation is 60 kg × 4 mL/kg × 35% burns = 8400 mL per day; half of this amount should be infused within the first 8 hours. 2100 mL, 6300 mL, and 8400 mL are incorrect calculations.

The nurse is caring for a client with wound dressings to the burns on 55% of the body. The dressing changes are very painful, and the client rates them 7/10 on the pain scale. The client has morphine 2 mg to be administered by mouth every 2 hours as needed. When planning the client's care, when does the nurse decide to administer the medication? A. 15 minutes before the dressing change B. 60 minutes before the dressing change C. Along with a stool softener each time it is administered D. Only if the client rates pain between 8 and 10 on the pain scale

B. 60 minutes before the dressing change Rationale: Oral morphine takes 30 to 90 minutes to reach peak effect and can be administered at least 60 minutes before the dressing change. Although pain medications can cause constipation, the nurse would not administer a stool softener each time the morphine is administered. If the client is experiencing pain and rates it anywhere on the pain scale, the client can receive pain medication if it is within the timeframe. It is important to premedicate a client before a painful procedure.

The nurse is assessing a client with severe burn wounds. What are the nursing interventions performed by the nurse in the order of priority? A. Caring for the burn wound B. Checking for a patent airway C. Performin adequate fluid replacement D. Maintaining effective circulation

B. Checking for a patent airway D. Maintaining effective circulation C. Performin adequate fluid replacement A. Caring for the burn wound Rationale: The priority nursing intervention for a client with severe burn wounds is checking for a patent airway. The next priority is to maintain effective circulation. Then, adequate fluid replacement is established. Once a patent airway, effective circulation, and adequate fluid replacement have been established, priority is given to care of the burn wound.

A client is admitted to the emergency department with burns to the anterior trunk, entire right arm, and anterior right leg. The practitioner prescribes morphine sulfate for pain. What route of administration should the nurse expect to administer this medication? A. Orally B. Intravenously C. Subcutaneously D. Intramuscularly

B. Intravenously Rationale: The intravenous route is the preferred route for medication for a client with impaired peripheral circulation. Oral medications usually are not given to burn clients because of the frequent occurrence of paralytic ileus; oral analgesics take too long to provide immediate relief from pain. Impaired peripheral circulation does not permit accurate prediction of the dose absorbed when it is administered subcutaneously. Impaired peripheral circulation does not permit accurate prediction of the dose absorbed when it is administered intramuscularly.

A 6-year-old child has partial-thickness burns of the face and upper chest. What is the priority nursing assessment for the first 24 hours? A. Wound sepsis B. Pulmonary distress C. Fear and separation anxiety D. Fluid and electrolyte imbalance

B. Pulmonary Distress Rationale: Inhalation burns are usually present with facial burns, regardless of the depth; the immediate threat to life is asphyxia resulting from irritation and edema of the respiratory passages and lungs. Although wound sepsis is a possible complication, it will not be evident until the third to fifth day. Although the child is probably fearful, maintaining a patent airway is the priority. This child is too old for separation anxiety; however, complications related to stress may occur later. Fluid losses may be extremely high but reach their maximum about the fourth day; the initial priority is maintaining a patent airway.

A client with burns develops a wound infection. The nurse plans to teach the client that local wound infections primarily are treated with what type of antibiotics? A. Oral B. Topical C. Intravenous D. Intramuscular

B. Topical Rationale: Topical antibiotics are applied directly to the wound and are effective against many gram-positive and gram-negative organisms found on the skin. Although oral, intravenous, and intramuscular antibiotics may be administered, they are most effective for systemic rather than local infections; the vasculature in and around a burn is impaired, and the medication may not reach the organisms in the wound.

A nurse is caring for a client who is experiencing the second (acute) phase of burn recovery. The common client response the nurse expects to identify during this phase of burn recovery is an increase in what? A. Serum sodium B. Urinary output C. Hematocrit level D. Serum potassium

B. Urinary Output Rationale: As fluid returns to the vascular system, increased renal flow and diuresis occur. An increase in the serum sodium level (hypernatremia) is not a common response identified during the second (acute) phase of burn recovery. An increase in the hematocrit level indicates hemoconcentration and hypovolemia; in the second phase of burn recovery, hemodilution and hypervolemia occur. During the second phase of burn recovery, potassium moves back into the cells, decreasing serum potassium.

A nurse is assessing the adequacy of a client's intravenous fluid replacement therapy during the first 2 to 3 days after sustaining full-thickness burns to the trunk and right thigh. What assessment will provide the nurse with the most significant data? A. Weights every day B. Urinary output every hour C. Blood pressure every 15 minutes D. Extent of peripheral edema every 4 hours

B. Urinary output every hour Rationale: A client with extensive burns has an indwelling urinary catheter so that urine output can be measured hourly. Urinary output reflects circulating blood volume; it is the most reliable, immediately available information to assess fluid needs. Although daily weights reflect fluid retention or loss, they are not as immediately accurate as hourly urine measurements. A blood pressure reading may indicate hypervolemia or hypovolemia, but it is not as accurate an indicator of fluid replacement as hourly urine output. Peripheral edema may have many causes; it is not an effective indicator of fluid balance.

Client A: Waxy white, dark-brown appearance Client B: Redness, pain, minimal edema Client C: Moist blebs, blisters, severe pain Client D: Dry, leathery eschar, absence of pain The nurse is examining four different clients who present with thermal burns. Which client does the nurse diagnose as having second-degree burns? A. Client A B. Client B C. Client C D. Client D

C. Client C Rational: Client C has second-degree burns. The client is experiencing severe pain and the skin shows moist blebs and blisters. Client A may have third- and fourth-degree burns, in which the skin is waxy white, dark brown in appearance. Client B may have first-degree burns, in which the skin is red in color with minimal edema and pain. Client D may have third- and fourth-degree burns as the skin is dry, leathery eschar and there is absence of pain.

A client with burns is hospitalized in the emergency department and advised to get an electrocardiogram (ECG) done. Which type of burn injury has the client most likely sustained? A. Flame burn B. Chemical burn C. Electrical burn D. Radiation burn

C. Electrical burn Rational: In an electrical burn injury, changes in the ECG may indicate damage to the heart. In flame burn injuries, the smoldering clothing and all metal objects are removed. If a client suffers from chemical burns, the dried chemicals present on skin should not be made wet but should be brushed off. If the client has radiation burn injuries, then the source should be removed using tongs or lead protective gloves.

A nurse is administering a histamine H2 antagonist to a client who has extensive burns. The nurse explains to the client that this drug is given prophylactically during the first few weeks after extensive burns. What complication of burns will it prevent? A. Colitis B. Gastritis C. Stress ulcer D. Metabolic acidosis

C. Stress ulcer Rationale: An ulcer of the upper gastrointestinal tract is related to excessive secretion of stress-related hormones, which increases hydrochloric acid production. Histamine H2 antagonists decrease acid secretion. Colitis is not a complication of burns. Gastritis is not a complication of burns. Metabolic acidosis is not a complication of burns unless hypermetabolism or renal failure occurs; metabolic acidosis is not treated with H2 antagonists.

Which image represents a deep full-thickness burn injury? A. Redness B. Arm with yellow blisters C. Hand with angry red fingers and spots on the hand D. Arm and hand with black necrosis and bone showing

D Rationale: Image 4 represents the typical appearance of a full-thickness burn injury. This injury has a hard, dry, leathery eschar formed from the coagulated particles of destroyed skin. Image 1 signifies a superficial partial-thickness burn injury. Image 2 also represents a superficial partial-thickness burn injury. Image 3 signifies the typical appearance of a deep partial-thickness burn injury.

Which wound care is given to a client with severe burn injuries during the acute phase? A. Assess extent and depth of burns B. Provide daily shower and wound care C. Remove dead and contaminated tissue D. Assess the wound daily and adjust the dressing

D. Assess the wound daily and adjust the dressing Rationale: In the acute phase, wound care is given by assessing the wound daily and adjusting the dressing if necessary according to the protocols. Assessing the extent and depth of burns is performed in the emergent phase. Providing a daily shower and removing the dead and contaminated tissue (debride) is performed in the emergent phase.

The primary healthcare provider instructs the nurse to monitor serum creatinine and blood urea nitrogen in a client who is on therapy for burn wounds. Which medication most likely has been prescribed to the client? A. Nitrofurantoin B. Mafenide acetate C. Silver sulfadiazine D. Gentamicin sulfate

D. Gentamicin sulfate Rationale: Gentamicin sulfate may cause nephrotoxicity in the client; therefore the client who is prescribed this drug should be carefully monitored for serum creatinine and blood urea nitrogen. The client on nitrofurantoin should be closely observed for signs of allergic reactions. Blood gas and serum electrolyte levels should be monitored in clients on mafenide acetate. In clients who are on silver sulfadiazine, wounds should be monitored for infections.

A client who sustained burn injuries due to a fire and explosion has a carbon monoxide level of 14%. Which pathophysiologic risk is increased in the client? A. Stupor B. Vertigo C. Convulsions D. Slight breathlessness

D. Slight breathlessness Rational: Slight breathlessness may occur when the carbon monoxide level is 14%. Stupor and vertigo may result when the carbon monoxide level is in between 21% and 40%. When the level of carbon monoxide reaches between 41% and 60%, coma or convulsions may occur.