NCLEX - burns

procedures to remove escahr

-hydrotherapy -debridement

The Emergency Department triage nurse encounters a client who says that he has received exposure to a liquid hazardous chemical at work. He reports that he is only 1 of about 20 people. What should the nurse do? You answered this question Incorrectly 1. Call the supervisor and inform of the possibility of contamination in the surrounding space. 2. Obtain vital signs immediately. 3. Call personnel trained in containment and decontamination immediately. 4. Direct the individual to a bed space immediately. 5. Instruct the client to remove clothing and put on disposable hospital gown.

1. & 3. Correct: The nurse should report this to the supervisor who can determine the next action to take regarding isolation, decontamination, and use of the current space. Those who are trained in hazardous exposures should be informed immediately so that appropriate action is taken. These actions are priority for minimizing the exposure of clients and staff to the hazardous chemical. 2. Incorrect: The nurse should avoid contact with the client until personnel trained for handling hazardous exposures are present. 4. Incorrect: Containment is necessary to prevent further contamination of the space and individuals in the area. Directing the client to a bed space would not be containment. 5. Incorrect. The client may need to be directed to a decontamination area to prevent further contamination of the area, so removing clothing before going to this area would put others at risk for exposure to the hazardous chemical.

A client has arrived in the emergency department with partial thickness burns to 52 percent of the body. Which central venous pressure (CVP) reading would the nurse anticipate? You answered this question Correctly 1. 1 mm of Hg 2. 2 mm of Hg 3. 6 mm of Hg 4. 10 mm of Hg

1. Correct: Normal CVP is 2-6mmHg. This CVP reading indicates fluid volume deficit. A client with 52 percent of the body burned with partial thickness burns would lose fluid from the vascular space out into the tissues resulting in fluid volume deficit. 2. Incorrect: This is a normal CVP reading. Normal CVP is 2 to 6 mm of Hg. 3. Incorrect: This is a normal CVP reading. Normal CVP is 2 to 6 mm of Hg. 4. Incorrect: An increased CVP reading indicates fluid volume excess. There is no indication in the stem that the client is experiencing a fluid volume excess.

For a client with a major burn, which evaluation criterion identified by the nurse best indicates that fluid resuscitation has been effective during the first 24 hours of care? You answered this question Correctly 1. Urine output of 860 mL / 24 hours. 2. Increase in weight from preburn weight. 3. Heart rate of 122 beats per minute 4. Central venous pressure of 18 mm

1. Correct: Urine output is the best indicator of adequate fluid replacement during the first 24 hours. 2. Incorrect: The weight is not a good indicator now because of the large volume of fluids being infused. These extra fluids would increase the weight. Edema is a problem because of third spacing. 3. Incorrect: The heart rate should come down with adequate fluid replacement. 4. Incorrect: The CVP reading is too high. This indicates that too many fluids have been given.

The nurse is caring for a burn client in the emergent phase. The client becomes extremely restless while on a ventilator. What is the priority nursing assessment? You answered this question Correctly 1. Patency of endotracheal tube. 2. Adventitious breath sounds. 3. Fluid in the ventilator tubing. 4. Ventilator settings.

1. Correct: With restlessness, think hypoxia so the nurse should start assessment with airway first. Check for patency of the ET tube. If this is patent, then the other options would be next. 2. Incorrect: This is the next best answer, but hypoxia and airway comes first. 3. Incorrect: This is the third step. Rule out the other two before checking tubing for kinks or obstructions. 4. Incorrect: Start with the client first. Then move toward the ventilator. Always assess the client first.

A nurse plans to educate a group of new parents about how to prevent burn injuries in children. What should the nurse include? You answered this question Correctly 1. Eliminate use of placemats. 2. Establish "no" zones for space heaters. 3. Cover unused electrical outlets. 4. Warm baby bottle in microwave for 30 seconds. 5. Set the hot water heater thermostat to 140°F (60°C).

1., 2., & 3. Correct: Placemats and tablecloths can be pulled down by children. If something hot is sitting on it, the child can be scalded. The parents should be taught to block access to stove, fireplace, space heaters, and water heaters. They need to be inaccessible to small children. Covering unused electrical outlets will prevent a child from sticking things, such as a fork, in it which could result in an electrical burn. 4. Incorrect: The parents should not use microwave at all for warming the bottle. Food and liquids can heat unevenly and burn the child. 5. Incorrect: Hot water heater thermostats should be set to below 120°F (48.9°C). Bath water should be around 100°F (38°C) to prevent burn injuries with children. The water should be tested before allowing the child to step into the bath also.

A client arrives at the emergency department (ED) after sustaining a high-voltage electrical injury. Which interventions should the nurse initiate in the ED? You answered this question Correctly 1. Assess entry and exit wound. 2. Monitor vital signs. 3. Monitor for myoglobinuria. 4. Connect to cardiac monitor. 5. Perform the rule of nines.

1., 2., 3., & 4. Correct: These are correct interventions for the nurse to initiate when caring for a client who has sustained a high-voltage electrical injury. Remember, electricity kills vessels, nerves, and organs. 5. Incorrect: The rule of nines would not be used for an electrical injury. Visual examination is not predictive of burn size and severity with an electrical burn injury.

Tx of Carbon Monoxide poisoning?

100% O2 via nonrebreather mask pulse ox could be normal - still give 02 just detects that hemoglobin is bound

A client weighing 155 pounds (70 kg) is admitted to the burn unit with second and third degree burns covering 40% total body surface area. Normal Saline IV fluid resuscitation is ordered at 4 mL/kg per percentage of total body surface area burned over the first 24 hours. How much fluid does the nurse calculate the client will receive in 24 hours? Provide your answer using numbers and decimal points only.

11,200

when are you most likely to go into shock after a burn

1st 24 hours

What action should the nurse take first for the 5 year old client brought to the urgent care clinic with a blistering sunburn? You answered this question Correctly 1. Administer analgesics. 2. Apply cool water soaks. 3. Check immunization status for tetanus. 4. Educate family to avoid greasy lotions or butter on the burn.

2

A client received a severe burn to the right hand. When dressing the wound, it is important for the nurse to do what? You answered this question Incorrectly 1. Apply a wet to dry dressing for debridement. 2. Wrap each digit individually to prevent webbing. 3. Open blisters to allow drainage prior to dressing. 4. Allow the client to do as much of the dressing change as possible.

2. Correct: Each finger must be wrapped individually to prevent webbing. If not done appropriately the client could develop contractures and lose functional use of the hand. 1. Incorrect: No debridement is needed if dressing changes are done as ordered. 3. Incorrect: Blisters should be left intact so as not to create an open wound and an environment for infection to easily start. 4. Incorrect: This is not appropriate at this time and is not the most important option for the nurse to do to properly care for the wound and enhance healing.

A client with asthma has been admitted to the emergency room with sustained burns to the upper torso, face, and neck as a result of a steam injury when a pressure cooker exploded at home. Which intervention is the nurse's priority? You answered this question Incorrectly 1. Initiate high flow oxygen. 2. Prepare for endotracheal intubation. 3. Administer 1000mL of lactate ringers (LR). 4. Assess for altered level of consciousness (LOC).

2. Correct: Intubation must be accomplished quickly while a tube can still be inserted. The burn clients neck and facial area may become edematous due to capillary permeability. 1. Incorrect: The clients airway is the initial concern. The ventilation of the client is the next step. Respiratory distress is an increase potenial due to pre existing diagnosis of asthma. 3. Incorrect: Fluid resuscitation is needed, however, airway comes first. The client will need IV fluids to replace the transfer of plasma to interstitual tissue. 4. Incorrect: Inserting a endotracheal tube to maintain an airway is the nurse's priority intervention. The client should then be evaluated for any neurological deficits.

how many hrs do you have to give IV fluids for burns

24 must do it based on time of injury, not when they arrived in hospital

The emergency department nurse is assuming care of a client with full thickness burns to both legs. Which primary healthcare provider prescription should be implemented first? You answered this question Incorrectly 1. Administer IV morphine 2. Insert oropharyngeal airway 3. Start two large bore IVs 4. Apply silver sulfadiazine to burn area

3. Correct: Full thickness burns of both legs would result in a severe fluid volume deficit. A priority treatment for burns include fluid replacement; therefore, insertion of 2 large bore IVs is a priority. 1. Incorrect: Pain is important but not priority over fluid volume status. Remember, pain never killed anybody. 2. Incorrect: This client does not have airway involvement. These burns are on the legs; there is no indication in the stem that the airway is involved. 4. Incorrect: Application of silver sulfadiazine does not take priority over fluid replacement.

he nurse is monitoring the healing of a full-thickness wound to a client's right thigh. The wound has a small amount of blood during the wet to dry dressing change. What action should the nurse initiate next? You answered this question Correctly 1. Notify the primary healthcare provider. 2. Obtain wound culture. 3. Document the findings. 4. Remove dressing and leave open to air.

3. Correct: Look at the clues: full thickness wound, small amount of blood, wet to dry dressing. With a full thickness wound there is destruction of the epidermis, dermis, and subcutaneous tissues going down to the bone. ​So you would expect to see a small amount of blood or drainage wouldn't you? Yes. This is expected. Simply document this normal finding. 1. Incorrect: Is there really anything to worry about in this situation? No, so you do not need to notify healthcare provider. Now, with most questions on NCLEX there is something to worry about but just not with this one. 2. Incorrect: No, bleeding is not a sign of infection which is what you would be worried about if you got a wound culture. 4. Incorrect: Probably not, just a sign of blood flow in healing wound. Wet to dry dressing helps to debride the wound. So if you remove the dressing will debridement occur? No.

What is the nurse's first priority when treating a client with a chemical burn? You answered this question Incorrectly 1. Attach client to a cardiac monitor. 2. Apply a sterile bandage. 3. Rinse the area with copious amounts of water. 4. Remove the client's clothing.

3. Correct: The first action in treating a chemical burn is to rinse the affected area with large amounts of cool water. The only time this is avoided is with lye or white phosphorus. 1. Incorrect: This is necessary with electrical burns. 2. Incorrect: This may come later, not first priority. 4. Incorrect: This can be accomplished while you are rinsing them with water.

What would be the nurse's priority for a child who has arrived at the emergency department after sustaining a severe burn? You answered this question Correctly 1. Start intravenous fluids. 2. Provide pain relief. 3. Establish airway. 4. Place an indwelling catheter.

3. Correct: This stem does not tell you where the child's burns are, however, you are told that the burns are severe. So assume the worse. What are you most worried about the child losing? Yes, the airway. So we want to assess, establish, and maintain an airway. 1. Incorrect: Not before airway. This child will need IV fluid resuscitation within the first 24 hours. But if you can only pick one action to complete first, it better be to make sure the airway is patent. Then you can start the IV or delegate the task to someone else. 2. Incorrect: Give pain med after starting the IV, not before airway. The best pain relief method for a severe burn is going to be through the IV route. But we must make sure the airway is patent first. 4. Incorrect: Give the pain medication before placing the indwelling catheter but not before establishing the airway. Intake and output will need to be closely monitored in the client who is severely burned. But again, it will need to be done after establishing a patent airway.

parkland formula

4 mL x Body Weight (kg) x % surface area burned -- first half over first 8 hours -- remainder over next 16 hours

VS after a burn

FVD from edema so: -decreased CO -decreased UO -tachy -hypotension first (epi secreted so blood is shunted to vital organs)

what do we monitor with albumin

FVE - monitor CVP

what to do with chemical burn

Remove client from chemical and begin flushing Flush for 15-20 minutes

what is the most reliable noninvasive assessment of CO

UOP

how do you determine if fluid volume given is adequate

UOP 30-50 an hour

what meds are given to burn pts

albumin - helps correct FVD (increases kidney perfusion/BP/CO) IV pain meds tetanus immune globulin for immediate protection (passive immunity)

emergency management of burns

assess for airway patency administer 02 VS IV fluid elevate extremities (diuretics not used for edema) keep pt warm place on NPO take clothing and jewelry off

what can you do to stop burning process

blanket cool water

why are abx alternated what kind of abx

build resistance/tolerance no broad spectrum - will cause secondary infection

what to do if the urine is brown or red?

call dr myoglobin released when cells damaged

what is the most common airway injury

carbon monoxide poisoning

patho of carbon monoxide poisoning

carbon monoxide travels much faster than o2 and binds to hemoglobin first hemoglobin carrying carbon monoxide instead of 02 now -> tissue hypoxia

What can circumferential burns to extremities cause?

compartment syndrome (vascular compromise)

why is NGT put in

could develop paralytic ileus (gastric secretions built up in somtach) *decrease blood flow *ddecreased GI motility during stress

Concern with hydrotherapy

cross contamination of wounds

what fluid is given for burns

crystalloid (LR)

will you have decreased or increased CO after burn? UOP?

decreased for both

what med is usually not given to burn pt

diuretics don't want to decrease CO any more

can escharotomy/fasciotomy be performed without anesthesia

eschar - yes, nerve endings destroyed fasciotomy will be under gen anesthesia

Tx for compartment syndrome

escharotomy-cuts through eschar to relieve pressure fasciotomy - cut is through fascia of muscle

After 48 hours, the client will start to diurese. Fluid is going back into the vascular space. Now what could a potential problem be

fluid volume excess

Rule of 9 burns

head - 9 arms - 9 each front trunk - 18 back - 18 each leg - 18 genitals - 1

first thing to do for electrical burn

heart monitor for 24 hrs at risk for dysrhythmias (VFIB)

diet for burn pt

high protein/carb/fats 5000 cals need vitamin c

electrolytes after a burn

hyponatremia hyperkalemia

After a burn, why and when does plasma seep out into the tissue?

increased capillary permeability, vessels are damaged from the heat first 24 hrs

what drug could be ordered to flush out kidneys

mannitol

why IV over IM pain meds

must have adequate perfusion to muscle

s/e of mycin abx

nephrotoxicity ototoxicity

when can pt get off NPO and NGT taken out

once bowel sounds are heard

what lab to check to ensure proper nutrition

pre-albumin shortest half life most sensitive

why are antacids, h2 antagonists and PPIs prescribed

prevent stress ulcers (curling ulcer)

#1 priority with airway injuries from burns

prophylactically ETT

what type of isolation for burn pt

protective

what should you check with circumferential burns

pulse skin color skin temp cap refill

what to check before feedings

residual if a lot then that means slow peristalsis - hold feed

if a pt has shallow breaths, what acid base imbalance

resp acidosis

when is the rule of 9 done

right away in ER then 2-3 days after when wound is better demarcated

what do you do to help graft adhere

roll sterile gauze/qtip from middle to outside to get exudate from underneath

what to do to prevent contracvtures

splint wrap each finer separately hyperextend the neck NO PILLOW - will cause contracture

what is an autograft

uses pt own skin

can you use the same graft site multiple times

yes every 12-14 days

does eschar need to be remove

yes, new tissue can't regenerate bacteria grows in eschar