Prep-U Integumentary - Burns

A client with a burn over the lower leg asks why surgery is planned to remove the dead burned tissue. Which response will the nurse make?

"It reduces the risk of complications from an infection."

Which type of graft utilizes the client's own skin for wound coverage?

Autograft

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately?

Hoarseness of the voice

Which of the following neuroendocrine changes occur within the first 24 hours of a serious burn?

Hyperglycemia

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?

Identification by the destruction of the dermis and epidermis

The nurse is caring for a client with burns over 55% of total body surface area. Which information is essential for the nurse to document to guide the care of this client? Select all that apply.

Pre-burn body weight Current list of medications Last tetanus immunization Current body temperature

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?

The early appearance of the burn injury may change.

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?

27%

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.

7:30 p.m. to 9:30 p.m.; 24 to 36 hours

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?

Lund and Browder method

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?

Urine output of 20 ml/hour

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.

A client with a burn wound is prescribed mafenide acetate 5% twice daily. Nursing implications associated with this medication include

premedicating the client with an analgesic prior to application.

The nurse recognize what as an early sign of sepsis in a client with a burn injury?

Elevated serum glucose

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:

Epidermis and a portion of deeper dermis.

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?

allograft

The nurse is caring for a client 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 if it occurs immediately after burn injury?

Hyperkalemia

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.

The Face The Perineum

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?

escharotomy

A client is brought to the ED with burns exceeding 20% of total body surface area. Which is the primary nursing intervention in the care of this client

Fluid Resuscitation

What laboratory value observed by the nurse is unexpected during the fluid remobilization phase of a major burn?

Serum sodium level of 140 mEq/L

During the recovery of an extensive burn, the client is uncomfortable wearing the tight-fitting custom garment. Which is the best response by the nurse?

"A snug fit is needed to minimize scarring and to smooth the skin."

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?

"An allograft is a temporary wound covering obtained from cadaver skin."

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?

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

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?

180g/day

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?

2 to 4 weeks

A sample consensus formula for fluid replacement recommends that a balanced salt solution be administered in the first 24 hours of a chemical burn in the range of 2 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?

2400 mL

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?

36%

Acticoat antimicrobial barrier dressings used in the treatment of burn wounds can be left in place for which time frame?

5 days

Which of the following measures can be used to cool a burn?

Application of cool water

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?

Apply a cervical collar on the client

During the late stages of healing, which intervention helps a burn wound to heal with minimal scarring?

Applying continuous-compression wraps

In a client with burns on the legs, which nursing intervention helps prevent contractures?

Applying knee splints

A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern?

BUN: 28 mg/dL

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.

Base-bicarbonate deficit Elevated hematocrit level Sodium deficit

Which of the following skin substitutes is a nylon-silicone membrane coated with a protein?

Biobrane

Burn shock is characterized by which of the following?

Capillary leak

Which complication is common for victims of electrical burns?

Cardiac dysrhythmia

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?

Contact the primary care provider and prepare for an escharotomy.

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:

Dry and pale white.

When the nurse learns that the client suffered injury from a flash flame, the nurse anticipates which depth of burn?

Deep partial thickness

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?

Electrical burns usually follow an internal path.

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?

Full-thickness

Which type of burn injury requires skin grafting?

Full-thickness

A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client?

Gastric ulcers

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?

Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel.

A nurse provides care for a client with deep partial-thickness burns 48 hours after the burn. What would cause a reduced hematocrit in this client?

Hemodilution

What are the expected findings in the fluid remobilization phase (acute phase, diuresis) that the nurse should monitor for? Select all that apply.

Hemodilution Increased urinary output Sodium deficit

The nurse receives a client following a serious thermal burn. Which complication will the nurse take action to prevent first?

Hypovolemia

Which of the following types of shock will a nurse observe in a client with extensive burns?

Hypovolemic shock

A child tips a pot of boiling water onto his bare legs. The mother should:

Immerse the child's legs in cool water.

Which zone of burn injury sustains the most damage?

Inner

Which of the following is the effect of protein catabolism in a client with severe burns?

It compromises wound healing and immunocompetence.

Which of the following is the preferred IV fluid for burn resuscitation?

Lactated Ringer's (LR)

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?

Lactated Ringer's solution

Which type of debridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar?

Mechanical

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:

Pain Management

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?

Paralytic ileus

Which of the following topical burn preparations act as wick for sodium and potassium?

Silver nitrate solution

Following a burn injury, the nurse determines which area is the priority for nursing assessment?

Pulmonary System

Which of the following fluid or electrolyte changes occur in the emergent/resuscitative phase?

Reduction in blood volume

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:

Stasis

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?

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

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?

The client's urinary output is 0.5 mL/kg/hour.

Which is the primary reason for placing a client in a horizontal position while smothering flames are present?

To keep fire and smoke from airway

Following a burn, the nurse understands that the focused management of which burn zone is of greatest concern?

Zone of stasis

The nurse recognizes the first dressing change at the site of an autograft is performed

as soon as foul odor or purulent drainage is noted, or 2 to 5 days after surgery.

A client has received significant electrical burns in a workplace accident. What occurrence makes it difficult to assess internal burn damage in electrical burns?

deep tissue cooling

The nurse is preparing to provide wound care to a client with extensive burns. Which characteristic of the dressing will the nurse use to select the type of topical therapy? Select all that apply.

Penetrates eschar without toxicity Effectiveness against organisms Cost-effective and acceptable to the client Easy to apply and remove to minimize pain

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?

Preexisting conditions

A patient has been prescribed mafenide acetate cream for burn treatment. The nurse should educate the patient regarding which of the following?

Severe burning pain for up to 20 minutes

The nurse knows that which topical antibacterial agent does not penetrate eschar?

Silver nitrate 0.5%

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?

Escharotomy

A client recovering from burn injuries over both forearms reports itching of the wounds. Which action will the nurse take to enhance the client's comfort?

Instruct to pat and not scratch the areas.

A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene?

Irrigate the wounds with water.

Which of the following is the analgesic of choice for burn pain?

Morphine sulfate

The nurse determines which statement reflects current research regarding the utilization of nonpharmacological measures in the management of burn pain?

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

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:

wrap elastic bandages distally to proximally on dependent areas.

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?

Deep partial-thickness

A client who was severely burned begins to exhibit symptoms of renal failure during treatment. What physiologic process can cause acute renal failure?

hemoconcentration

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

tissue edema may interfere with drug absorption via other routes.

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 leathery. What depth of burn injury does the client have?

Full-thickness - 3rd degree

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 urinary output of 30 mL/hr

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.

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

When a client is receiving 100% oxygen, what is the key sign of onset of acute respiratory distress syndrome?

Hypoxemia

Which of the following would indicate the need to increase fluids beyond what is recommended for fluid resuscitation?

Myoglobin in the urine

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?

Roll the client in a blanket.

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.

Place the client in a horizontal position. Roll the client in a blanket to smother the fire.