MS3 - Exam 4 Burns

A 60-kg client has sustained third-degree burns over 40% of the body. Using the Parkland (Baxter) formula, the minimum fluid requirements are which during the first 24 hours after the burn? 1. 9600 mL of lactated Ringer's solution 2. 4800 mL of 0.9% normal saline solution 3. 2400 mL of 0.45% normal saline solution 4. 1200 mL of 5% dextrose in water solution

1. 9600 mL of lactated Ringer's solution The Parkland (Baxter) formula is 4 mL of lactated Ringer's solution × kg body weight × percent burn. The calculation is performed as follows: 4 mL × 60 kg × 40 = 9600 mL.

The community health nurse is providing a teaching session to firefighters in a small community regarding care of a burn victim at the scene of injury. The nurse instructs the firefighters that in the event of a tar burn, which is the immediate action? 1. Cooling the injury with water 2. Removing all clothing immediately 3. Removing the tar from the burn injury 4. Leaving any clothing that is saturated with tar in place

1. Cooling the injury with water Scald burns and tar or asphalt burns are treated by immediate cooling with saline solution or water, if available, or immediate removal of the saturated clothing. Clothing that is burned into the skin is not removed because increased tissue damage and bleeding may result. No attempt is made to remove tar from the skin at the scene.

The emergency department nurse is caring for a client who has sustained chemical burns to the esophagus after ingestion of lye. The nurse reviews the primary health care provider's prescriptions and should plan to question which prescription? 1. Gastric lavage 2. Intravenous (IV) fluid therapy 3. Nothing by mouth (NPO) status 4. Preparation for laboratory studies

1. Gastric lavage The client who has sustained chemical burns to the esophagus is placed on NPO status, is given IV fluids for replacement and treatment of possible shock, and is prepared for esophagoscopy and barium swallow to determine the extent of damage. Laboratory studies also may be prescribed. A nasogastric tube may be inserted, but gastric lavage and emesis are avoided to prevent further erosion of the mucosa by the irritating substances that these treatments involve.

A client taking calcium carbonate chewable tablets and ranitidine is on nothing by mouth (NPO) status and has a nasogastric (NG) tube in place after suffering bilateral burns to the legs. The nurse determines that the client's gastrointestinal (GI) status is least satisfactory if which finding is noted on assessment? 1. Gastric pH of 3 2. Absence of abdominal discomfort 3. GI drainage that is guaiac negative 4. Presence of hypoactive bowel sounds

1. Gastric pH of 3 The gastric pH should be maintained at 7 or greater with the use of prescribed antacids and histamine 2 (H2) receptor-blocking agents. Lowered pH (to the acidic range) in the absence of food or tube feedings can lead to erosion of the gastric lining and ulcer development. Absence of discomfort and bleeding (guaiac-negative drainage) are normal findings. The client's bowel sounds may be expected to be hypoactive in the absence of oral or NG tube intake.

A burn client is receiving treatments of topical mafenide acetate to the site of injury. The nurse monitors the client, knowing that which finding indicates that a systemic effect has occurred? 1. Hyperventilation 2. Elevated blood pressure 3. Local rash at the burn site 4. Local pain at the burn site

1. Hyperventilation Mafenide acetate is a carbonic anhydrase inhibitor and can suppress renal excretion of acid, thereby causing acidosis. Clients receiving this treatment should be monitored for signs of an acid-base imbalance (hyperventilation). If this occurs, the medication will probably be discontinued for 1 to 2 days. Options 3 and 4 describe local rather than systemic effects. An elevated blood pressure may be expected from the pain that occurs with a burn injury.

A client is seen in the ambulatory care clinic for a superficial burn to the arm. On assessing the skin at the burn injury, what will the nurse observe? 1. White color 2. Pink or red color 3. Weeping blisters 4. Insensitivity to pain and cold

2. Pink or red color Superficial burns are pink or red without any blistering. The skin blanches to touch, may be edematous and painful, and heals on its own, usually within 1 week. A white color characterizes deep partial-thickness burns. Weeping blisters characterize partial-thickness superficial burns. Deep full-thickness burns are associated with insensitivity to pain and cold.

The nurse is providing care for a client who sustained burns over 30% of the body from a fire. On assessment, the nurse notes that the client is edematous in both burned and unburned body areas. The client's wife asks why her husband "looks so swollen." What is the nurse's best response? 1."Constricted blood vessels have caused a loss of protein in the blood." 2."Leaking blood vessels have led to increased protein amounts in the blood." 3."Leaking blood vessels have led to decreased protein amounts in the blood." 4."Constricted blood vessels have led to increased protein amounts in the blood."

3."Leaking blood vessels have led to decreased protein amounts in the blood." In extensive burn injuries (greater than 25% of total body surface area), the edema occurs in both burned and unburned areas as a result of the increase in capillary permeability and hypoproteinemia. Edema also may be caused by the volume and oncotic pressure effects of the large fluid resuscitation volumes required.

The nurse is performing an assessment on a client who sustained circumferential burns of both legs. Which assessment would be the initial priority in caring for this client? 1. Assessing heart rate 2.Assessing respiratory rate 3.Assessing peripheral pulses 4.Assessing blood pressure (BP)

3.Assessing peripheral pulses The client who receives circumferential burns to the extremities is at risk for altered peripheral circulation. The priority assessment would be to assess for peripheral pulses to ensure that adequate circulation is present. Although the respiratory rate and BP also would be assessed, the priority with a circumferential burn is assessment for the presence of peripheral pulses because the airway is not affected in this case.

The nurse is caring for a client who was admitted to the burn unit after sustaining a burn injury covering 30% of the body. What is the most appropriate time frame for the emergent phase? 1. The entire period of time during which rehabilitation occurs 2. The period from the time the client is stable to the time when all burns are covered with skin 3. The period from the time the burn was incurred to the time when the client is admitted to the hospital 4. The period from the time the burn was incurred to the time when the client is considered physiologically stable

4. The period from the time the burn was incurred to the time when the client is considered physiologically stable The emergent phase of burn care generally extends from the time the burn injury is incurred until the time when the client is considered physiologically stable. The acute phase lasts until all full-thickness burns are covered with skin. The rehabilitation period lasts approximately 5 years for an adult and includes reintegration into society.

Silver sulfadiazine is prescribed for a client with a burn injury. Which laboratory finding requires the need for follow-up by the nurse? 1. Glucose level of 99 mg/dL (5.65 mmol/L) 2. Platelet level of 300,000 mm3 (300 × 109/L) 3. Magnesium level of 1.5 mEq/L (0.75 mmol/L) 4. White blood cell count of 3000 mm3 (3.0 × 109/L)

4. White blood cell count of 3000 mm3 (3.0 × 109/L) Silver sulfadiazine is used for the treatment of burn injuries. Adverse effects of this medication include rash and itching, blue-green or gray skin discoloration, leukopenia, and interstitial nephritis. The nurse should monitor a complete blood count, particularly the white blood cells, frequently for the client taking this medication. If leukopenia develops, the primary health care provider is notified and the medication is usually discontinued. The white blood cell count noted in option 4 is indicative of leukopenia. The other laboratory values are not specific to this medication and are also within normal limits.

A client sustains a burn injury to the entire right and left arms, the right leg, and the anterior thorax. According to the rule of nines, the nurse would assess that this injury constitutes which body percentage? Fill in the blank. 54 %

According to the rule of nines, the right arm is equal to 9% and the left arm is equal to 9%. The right leg is equal to 18% and the left leg is equal to 18%. The anterior thorax is equal to 18% and the posterior thorax is equal to 18%. The head is equal to 9% and the perineum is equal to 1%. If the anterior thorax, the right leg, and the right and left arms were burned, according to the rule of nines, the total area involved would be 54%.

The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy? 1. Return of distal pulses 2. Brisk bleeding from the site 3. Decreasing edema formation 4. Formation of granulation tissue

1. Return of distal pulses Escharotomies are performed to relieve the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential third-degree burn. The escharotomy releases the tourniquet-like compression around the arm. Escharotomies are performed through avascular eschar to subcutaneous fat. Although bleeding may occur from the site, it is considered a complication rather than an anticipated therapeutic outcome. Usually, direct pressure with a bulky dressing and elevation control the bleeding, but occasionally an artery is damaged and may require ligation. Escharotomy does not affect the formation of edema. Formation of granulation tissue is not the intent of an escharotomy.

The nurse is developing a nursing care plan for a client with a circumferential burn injury of the right arm. What is the nurse's priority action? 1.Monitor the radial pulse every hour. 2.Keep the extremity in a dependent position. 3.Document any changes that occur in the pulse. 4.Place pressure dressings and wraps around the burn sites.

1.Monitor the radial pulse every hour. In a client with ineffective tissue perfusion related to a circumferential burn injury, peripheral pulses should be assessed every hour for 72 hours. The affected extremities should be elevated, and the primary health care provider (PHCP) should be notified of any changes in pulses, capillary refill, or pain sensation. Pressure dressings and wraps should not be applied around the circumferential burn because they could cause a further alteration in peripheral circulation.

The industrial nurse is providing instructions to a group of employees regarding care to a client in the event of a chemical burn injury. The nurse instructs the employees that which is the first consideration in immediate care? 1.Removing all clothing, including gloves, shoes, and any undergarments 2. Determining the antidote for the chemical and placing the antidote on the burn site 3. Leaving all clothing in place until the client is brought to the emergency department 4. Lavaging the skin with water and avoiding brushing powdered chemicals off the clothing

1.Removing all clothing, including gloves, shoes, and any undergarments In a chemical burn injury, the burning process continues as long as the chemical is in contact with the skin. All clothing, including gloves, shoes, and undergarments, is removed immediately, and water lavage is instituted before and during transport to the emergency department. Powdered chemicals are first brushed off the client before lavage is performed.

The health education nurse provides instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which instructions should the nurse provide? Select all that apply. 1. Sunscreen should be applied every 8 hours. 2. Use sunscreen when participating in outdoor activities. 3. Wear a hat, opaque clothing, and sunglasses when in the sun. 4. Avoid sun exposure in the late afternoon and early evening hours. 5. Examine your body monthly for any lesions that may be suspicious.

2, 3, 5 The client should be instructed to avoid sun exposure between the hours of brightest sunlight: 10 a.m. and 4 p.m. Sunscreen, a hat, opaque clothing, and sunglasses should be worn for outdoor activities. The client should be instructed to examine the body monthly for the appearance of any cancerous or precancerous lesions. Sunscreen should be applied 30 minutes to 1 hour before sun exposure, and reapplied every 2 to 3 hours, and after swimming or sweating; otherwise, the duration of protection is reduced.

A client is brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply. 1.Restrict fluids. 2.Assess for airway patency. 3.Administer oxygen as prescribed. 4.Place a cooling blanket on the client. 5.Elevate extremities if no fractures are present. 6.Prepare to give oral pain medication as prescribed.

2, 3, 5 The primary goal for a burn injury is to maintain a patent airway, administer intravenous (IV) fluids to prevent hypovolemic shock, and preserve vital organ functioning. Therefore, the priority actions are to assess for airway patency and maintain a patent airway. The nurse then prepares to administer oxygen. Oxygen is necessary to perfuse vital tissues and organs. An IV line should be obtained and fluid resuscitation started. The extremities are elevated to assist in preventing shock and decrease fluid moving to the extremities, especially in the burn-injured upper extremities. The client is kept warm since the loss of skin integrity causes heat loss. The client is placed on NPO (nothing by mouth) status because of the altered gastrointestinal function that occurs as a result of a burn injury.

A client is brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply. 1. Restrict fluids. 2. Assess for airway patency. 3. Administer oxygen as prescribed. 4. Place a cooling blanket on the client. 5. Elevate extremities if no fractures are present. 6. Prepare to give oral pain medication as prescribed.

2, 3, 5 The primary goal for a burn injury is to maintain a patent airway, administer intravenous (IV) fluids to prevent hypovolemic shock, and preserve vital organ functioning. Therefore, the priority actions are to assess for airway patency and maintain a patent airway. The nurse then prepares to administer oxygen. Oxygen is necessary to perfuse vital tissues and organs. An IV line should be obtained and fluid resuscitation started. The extremities are elevated to assist in preventing shock and decrease fluid moving to the extremities, especially in the burn-injured upper extremities. The client is kept warm, because the loss of skin integrity causes heat loss. The client is placed on NPO (nothing by mouth) status because of the altered gastrointestinal function that occurs as a result of a burn injury.

The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse creates a postoperative plan of care for the client and should include which intervention in the plan? 1. Maintain the client in a prone position. 2. Elevate and immobilize the grafted extremity. 3. Maintain the grafted extremity in a flat position. 4. Keep the grafted extremity covered with a blanket.

2. Elevate and immobilize the grafted extremity. Autografts placed over joints or on lower extremities are elevated and immobilized after surgery for 3 to 7 days, depending on the surgeon's preference. This period of immobilization allows the autograft time to adhere and attach to the wound bed, and the elevation minimizes edema. Keeping the client in a prone position and covering the extremity with a blanket can disrupt the graft site.

A client is admitted to the hospital emergency department after receiving a burn injury in a house fire. The skin on the client's trunk is tan, dry, and hard. It is edematous but not very painful. The nurse determines that this client's burn should be classified as which type? 1. Superficial 2. Full-thickness 3. Deep partial-thickness 4. Partial-thickness superficial

2. Full-thickness Full-thickness burns involve the epidermis, the full dermis, and some of the subcutaneous fat layer. The burn appears to be a tan or fawn color, with skin that is hard, dry, and inelastic. Edema is severe, and the accumulated fluid compresses tissue underneath because of eschar formation. Some nerve endings have been damaged, and the area may be insensitive to touch, with little or no pain.

The nurse is evaluating fluid resuscitation attempts in the burn client. Which finding indicates adequate fluid resuscitation? 1. Disorientation to time only 2. Heart rate of 95 beats/minute 3. +1 palpable peripheral pulses 4. Urine output of 30 mL over the past 2 hours

2. Heart rate of 95 beats/minute When fluid resuscitation is adequate, the heart rate should be less than 120 beats/minute, as indicated in option 2. In addition, adequacy of fluid volume resuscitation can be evaluated by determining if urine output is at least 30 mL/hour, peripheral pulses are +2 or better, and the client is oriented to client, place, and time.

The nurse is planning care for a client who suffered a burn injury and has a negative self-image related to keloid formation at the burn site. The keloid formation is indicative of which condition? 1. Nerve damage 2. Hypertrophy of collagen fibers 3. Compromised circulation at the burn site 4. Increase in subcutaneous tissue at the burn site

2. Hypertrophy of collagen fibers Keloids are visible as excessive scar formation and result from hypertrophy of collagen fibers. Nerves conduct sensory and motor impulses from the skin. The vasculature provides blood vessels with nourishment and assists in thermoregulation. Subcutaneous tissue provides for heat insulation, mechanical shock absorption, and caloric reserve.

The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy? 1. Vital signs 2. Urine output 3. Mental status 4. Peripheral pulses

2. Urine output Successful or adequate fluid resuscitation in the client is signaled by stable vital signs, adequate urine output, palpable peripheral pulses, and clear sensorium. However, the most reliable indicator for determining adequacy of fluid resuscitation, especially in a client with burns, is the urine output. For an adult, the hourly urine volume should be 30 to 50 mL.

The nursing educator has just completed a lecture to a group of nurses regarding care of the client with a burn injury. A major aspect of the lecture was care of the client at the scene of a fire. Which statement, if made by a nurse, indicates a need for further instruction? 1."Flames should be doused with water." 2."The client should be maintained in a standing position." 3."Flames may be extinguished by rolling the client on the ground." 4."Flames may be smothered by the use of a blanket or another cover."

2."The client should be maintained in a standing position." The client should be placed or maintained in a supine position; otherwise, flames may spread to other parts of the body, causing more extensive injury. Flame burns may be extinguished by rolling the client on the ground, smothering the flames with a blanket or other cover, or dousing the flames with water.

A client is diagnosed with a full-thickness burn. What should the nurse anticipate will be used for final coverage of the client's burn wound? 1. Biobrane 2.Autograft 3.Xenograft 4.Homograft

2.Autograft A full-thickness burn will require terminal coverage with an autograft-the client's own skin. Biobrane is porcine collagen bonded to a silicone membrane, which is temporary and lasts anywhere from 10 to 21 days. Homografts (cadaveric skin) and xenografts (pigskin) provide temporary coverage of the wound by acting as a dressing for up to 3 weeks before rejecting.

The nurse is planning care for a client who suffered a burn injury and has a negative self-image related to keloid formation at the burn site. The keloid formation is indicative of which condition? 1.Nerve damage 2.Hypertrophy of collagen fibers 3.Compromised circulation at the burn site 4.Increase in subcutaneous tissue at the burn site

2.Hypertrophy of collagen fibers Keloids are visible as excessive scar formation and result from hypertrophy of collagen fibers. Nerves conduct sensory and motor impulses from the skin. The vasculature provides blood vessels with nourishment and assists in thermoregulation. Subcutaneous tissue provides for heat insulation, mechanical shock absorption, and caloric reserve.

The nurse has developed a nursing care plan for a client with a burn injury to implement during the EMERGENT phase. Which priority intervention should the nurse include in the plan of care? 1.Monitor vital signs every 4 hours. 2.Monitor mental status every hour. 3.Monitor intake and output every shift. 4.Obtain and record weight every other day.

2.Monitor mental status every hour. During the EMERGENT phase after a burn injury, because of fluid volume deficits secondary to a burn injury, vital signs should be monitored every hour (every 4 hours is too infrequent) until the client is hemodynamically stable. The nurse should monitor the mental status of the client every hour for the first 48 hours. The weight should be obtained and recorded daily or twice daily, and intake and output measurements should be recorded on an hourly basis.

An adult client trapped in a burning house has suffered burns to the back of the head, the upper half of the posterior trunk, and the back of both arms. Using the rule of nines, what percentage does the nurse determine the extent of the burn injury to be? Fill in the blank.

22.5% According to the rule of nines, the posterior side of the head equals 4.5%, the back of both arms equals 9%, and the upper half of the posterior trunk equals 9%, totaling 22.5%.

An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury? 1. 18% 2. 24% 3. 36% 4. 48%

3. 36% According to the rule of nines, with the initial burn, the anterior half of the head equals 4.5%, the upper half of the anterior torso equals 9%, and the lower half of both arms equals 9%. The subsequent burn included the posterior half of the head, equaling 4.5%, and the upper half of the posterior torso, equaling 9%. This totals 36%.

The nurse is performing an assessment on a client admitted to the nursing unit who has sustained an extensive burn injury involving 45% of total body surface area. When planning for fluid resuscitation, the nurse should consider that fluid shifting to the interstitial spaces is greatest during which time period? 1. Immediately after the injury 2. Within 12 hours after the injury 3. Between 18 and 24 hours after the injury 4. Between 42 and 72 hours after the injury

3. Between 18 and 24 hours after the injury The maximum amount of edema in a client with a burn injury is seen between 18 and 24 hours after the injury. With adequate fluid resuscitation, the transmembrane potential is restored to normal within 24 to 36 hours after the burn. The remaining options are incorrect.

The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client? 1. Out-of-bed activities 2. Bathroom privileges 3. Immobilization of the affected leg 4. Placing the affected leg in a dependent position

3. Immobilization of the affected leg Autografts placed over joints or on the lower extremities after surgery often are elevated and immobilized for 3 to 7 days. This period of immobilization allows the autograft time to adhere to the wound bed. Getting out of bed, going to the bathroom, and placing the grafted leg dependent would put stress on the grafted wound.

A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mm Hg, a pulse rate of 110 beats/minute, and a urine output of 20 mL over the past hour. The nurse reports the findings to the primary health care provider (PHCP) and anticipates which prescription? 1. Transfusing 1 unit of packed red blood cells 2. Administering a diuretic to increase urine output 3. Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour 4. Changing the IV lactated Ringer's solution to one that contains 5% dextrose in water

3. Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour Fluid management during the first 24 hours following a burn injury generally includes the infusion of (usually) lactated Ringer's solution. Lactated Ringer's solution is an isotonic solution that contains electrolytes that will maintain fluid volume in the circulation. Fluid resuscitation is determined by urine output, and hourly urine output should be at least 30 mL/hour. The client's urine output is indicative of insufficient fluid resuscitation, which places the client at risk for inadequate perfusion of the brain, heart, kidneys, and other body organs. Therefore, the PHCP would prescribe an increase in the amount of IV lactated Ringer's solution administered per hour. There is nothing in the situation that calls for blood replacement, which is not used for fluid therapy for burn injuries. Administering a diuretic would not correct the problem because fluid replacement is needed. Diuretics promote the removal of the circulating volume, thereby further compromising the inadequate tissue perfusion. Intravenous 5% dextrose solution is isotonic before administered but is hypotonic once the dextrose is metabolized. Hypotonic solutions are not appropriate for fluid resuscitation of a client with significant burn injuries.

A client sustained a burn from cutaneous exposure to lye. At the site of injury, copious irrigation to the site was performed for 1 hour. On admission to the hospital emergency department, the nurse assesses the burn site. Which findings would indicate that the chemical burn process is continuing? 1. Eschar 2. Intact blisters 3. Liquefaction necrosis 4. Cherry-red, firm tissue

3. Liquefaction necrosis Alkalis, such as lye, cause a liquefaction necrosis, and exposure to fat results in formation of a soapy coagulum. Thick, leathery eschar forms with exposure to acids or heat. Intact blisters indicate a partial-thickness thermal injury. Cherry-red, firm tissue

Silver sulfadiazine is prescribed for a client with a partial-thickness burn, and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments? 1. "The medication is an antibacterial." 2. "The medication will help heal the burn." 3. "The medication should be applied directly to the wound." 4. "The medication is likely to cause stinging every time it is applied."

4. "The medication is likely to cause stinging every time it is applied." Silver sulfadiazine is an antibacterial that has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. It is applied directly to the wound to assist in healing. It does not cause stinging when applied.

A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the client? 1. 100% oxygen via an aerosol mask 2. Oxygen via nasal cannula at 6 L/minute 3. Oxygen via nasal cannula at 15 L/minute 4. 100% oxygen via a tight-fitting, nonrebreather face mask

4. 100% oxygen via a tight-fitting, nonrebreather face mask If an inhalation injury is suspected, administration of 100% oxygen via a tight-fitting nonrebreather face mask is prescribed until carboxyhemoglobin levels fall (usually below 15%). In inhalation injuries, the oropharynx is inspected for evidence of erythema, blisters, or ulcerations. The need for endotracheal intubation also is assessed. Administration of oxygen by aerosol mask and cannula are incorrect and would not provide the necessary oxygen supply needed for adequate tissue perfusion for the client with a likely inhalation injury.

The camp nurse asks the children preparing to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sunscreens are most effective when applied at which times? 1. Immediately before swimming 2. 5 minutes before exposure to the sun 3. Immediately before exposure to the sun 4. At least 30 minutes before exposure to the sun

4. At least 30 minutes before exposure to the sun Sunscreens are most effective when applied at least 30 minutes before exposure to the sun so that they can penetrate the skin. All sunscreens should be reapplied after swimming or sweating.

The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury? 1. Decreased heart rate 2. Increased urinary output 3. Increased blood pressure 4. Elevated hematocrit levels

4. Elevated hematocrit levels The resuscitation/emergent phase begins at the time of injury and ends with the restoration of capillary permeability, usually at 48 to 72 hours following the injury. During the resuscitation/emergent phase, the hematocrit level increases to above normal because of hemoconcentration from the large fluid shifts. Hematocrit levels of 50% to 55% (0.50 to 0.55) are expected during the first 24 hours after injury, with return to normal by 36 hours after injury. Initially, blood is shunted away from the kidneys and renal perfusion and glomerular filtration are decreased, resulting in low urine output. The burn client is prone to hypovolemia, and the body attempts to compensate by increased pulse rate and lowered blood pressure. Pulse rates are typically higher than normal, and the blood pressure is decreased as a result of the large fluid shifts.

The nurse is caring for a client with full-thickness circumferential burns of the entire trunk of the body who is on a mechanical ventilator. Which finding suggests that an escharotomy may be necessary? 1. Pallor of all extremities 2. Pulse oximetry reading of 93% 3. Peripheral pulses are diminished 4. High pressure alarm keeps sounding on the ventilator

4. High pressure alarm keeps sounding on the ventilator A client with a circumferential burn of the entire trunk likely will be on a ventilator because of the potential for breathing to be affected by this injury. The high pressure alarm will sound on the ventilator when there is any kind of obstruction. If the chest cannot expand due to restriction by eschar and increasing edema, this results in obstruction.

A client who is being evaluated for thermal burn injuries to the arms and legs complains of thirst and asks the nurse for a drink. Which action by the nurse is most appropriate? 1. Allow the client to have full liquids. 2. Give the client small glasses of clear liquids. 3. Order the client a full meal tray with extra liquids. 4. Keep the client on NPO (nothing by mouth) status.

4. Keep the client on NPO (nothing by mouth) status. The client should be maintained on NPO status because burn injuries frequently result in paralytic ileus. The client also should be told that fluids could cause vomiting because of the effect of the burn injury on gastrointestinal tract functioning. Mouth care should be given as appropriate to alleviate the sensation of thirst.