PrepU - Adult: Chapter 53
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.
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.
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 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 restriction
A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of their body. What would be the nurse's priority concern in the immediate care of this patient?
Fluid status
A male patient is brought to the emergency department (ED) from the site of a chemical fire. The paramedics report that the patient has a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. When the nurse assesses the patient, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the patient's right arm?
Full-thickness
Which type of burn injury requires skin grafting?
Full-thickness
A patient will be receiving biologic dressings. The nurse understands that biologic dressings, which use skin from living or recently deceased humans, are known by what name?
Homografts
A nurse who is contributing to the care of a patient with burns recognizes that the patient's injuries are associated with severe and debilitating pain at nearly all stages of treatment and recovery. What pharmacological intervention is most commonly used in the treatment of burn pain?
Intravenous morphine
A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene?
Irrigate the wounds with water.
Acticoat has been ordered as a component of a burn patient's wound care and infection control regimen. When applying this wound care product, the nurse should:
Moisten the Acticoat with sterile water and then apply it to the wound bed.
The nurse is documenting an hourly assessment of a patient who is being treated for full-thickness burns to his lower extremities. Assessment has revealed that the patient's abdominal girth is steadily increasing. This is most likely attributable to what pathophysiological process?
Third spacing
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
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 most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to
decrease catabolism.
Specific potential complications are common to specific types of burns. Which burns can impair ventilation?
face, neck, chest
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. How would the nurse document the depth of burn injury this client has?
full thickness (third degree)
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?"
When using the Palmer method to estimate the extent of a small or scattered burn injury, the nurse recognizes the palm is equal to which percentage of total body surface area?
1
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."
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?
2,400 mL
The emergency department nurse has just admitted a patient with a burn. The nurse recognizes that the patient is likely to require a nasogastric tube when the burn exceeds a total body surface area (TBSA) of what percentage?
25%
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 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%
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?
36%
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
The nurse is caring for a patient who sustained a deep partial-thickness burn injury 36 hours ago. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to which of the following nursing diagnoses?
Acute pain
A teenage boy has been brought by ambulance to the emergency department from a house fire in which he has suffered extensive injuries. In addition to burns, early blood tests reveal carbon monoxide poisoning. This assessment finding will be treated by what intervention?
Administration of 100% oxygen
In a client with burns on the legs, which nursing intervention helps prevent contractures?
Applying knee splints
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.
Which of the following is a disadvantage of surgical debridement?
Bleeding
The nurse receives a client following a serious thermal burn. Which complication will the nurse take action to prevent first?
Hypovolemia
A client with superficial burns on the face and deep partial-thickness burns on the neck and chest is undergoing treatment and is anxious to know about skin grafting. For which of the following areas can skin grafting be suggested?
Neck and chest
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 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.
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.
A patient in the emergent/resuscitative phase of a burn injury has had her lab work drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what?
Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis
The triage nurse in the emergency department (ED) receives a phone call from a frantic father who saw his 4-year-old child tip a pot of boiling water onto her chest. The father has called an ambulance. What would the nurse in the ED receiving the call instruct the father to do?
Immerse the child in a cool bath.
A child tips a pot of boiling water onto his bare legs. The mother should:
Immerse the child's legs in cool water.
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 patient has just been admitted after experiencing severe burns in an automobile accident. What intravenous solution should the nurse anticipate administering during this patient's immediate care?
Lactated Ringer's
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 patient is recovering from a burn that she experienced 6 weeks earlier. What is a priority in the rehabilitation and predischarge phase of the burn injury?
Patient and family education
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
Following a burn injury, the nurse determines which area is the priority for nursing assessment?
Pulmonary system
The nurse is providing wound care for a client with burns to the lower extremities. Which topical antibacterial agent carries a side effect of leukopenia that the nurse should monitor for within 48 hours after application?
Sulfadiazine, silver (Silvadene)
Which of the following is a potential cause of a superficial partial-thickness burn?
Sunburn
A patient has a burn injury that has damaged the epidermis. There are no blisters, and the skin is pink in color. This type of burn injury would be documented as which of the following?
Superficial
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 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 nurse is providing care to a client who has sustained a major burn injury. When developing the client's plan of care, the nurse anticipates that the greatest amount of fluid shifting would occur at which time?
about 24 hours after the burn
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?
Use client's palm size
The nursing care plan of a patient who is in the acute/immediate phase of burn care identifies a nursing diagnosis of Risk for Infection due to burns. What intervention should be prioritized in response to this diagnosis?
Vigilant application of infection-control precautions such as gloves, gowns, and masks
The emergency department (ED) team is conducting immediate care of a patient admitted with burns estimated at 40% total body surface area. The nurse in the ED and the other members of the team are aware of the need to customize the rate of fluid resuscitation and will base this rate on what data?
Vital signs and urine output
The occupational health nurse is called to the floor of the factory where a patient has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to "cool the burn." How should the nurse cool the burn?
Wrap cool towels around the affected extremity intermittently.
A client with deep partial-thickness and full-thickness burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse provides additional client teaching because these exercises may:
dislodge the autografts.
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 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
A client who was severely burned begins to exhibit symptoms of renal failure during treatment. What physiologic process can cause acute renal failure?
hemoconcentration
A client who has been burned significantly is taken by air ambulance to the burn unit. What physiologic process furthers a burn injury?
inflammatory
A nurse is developing a care plan for a client recovering from a serious thermal burn. After maintaining respirations, the nurse knows that the most important immediate goal of therapy is:
maintaining the client's fluid, electrolyte, and acid-base balance.
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.