PU CH57 BURNS PART I

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? A. full thickness (third degree) B. superficial (first degree) C. superficial partial-thickness or deep partial-thickness (second degree) D. fourth degree

A

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? A. "It reduces the risk of complications from an infection." B. "It reduces the amount of scarring that will occur on the skin." C. "It reduces the amount of wound care that you will need as the skin heals." D. "it encourages your body's natural processes to liquefy any damaged tissue."

A

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: A. stasis. B. coagulation. C. hyperemia. D. hypotension.

A

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? A. allograft B. xenograft C. autograft D. slit graft

A

When the nurse learns that the client suffered injury from a flash flame, the nurse anticipates which depth of burn? A. Deep partial thickness B. Superficial partial thickness C. Full thickness D. Superficial

A

Which antimicrobials is not commonly used to treat burns? A. tetracycline B. silver sulfadiazine (Silvadene) C. mafenide (Sulfamylon) D, silver nitrate (AgNO3) 0.5% solution

A

Which intervention helps to minimize the risk of further injury to an affected person at the scene of a fire? A. Roll the client in a blanket B. Cover the client with a wet cloth C. Place the client with the head positioned slightly below the rest of the body D. Avoid immediate IV fluid therapy

A

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. A. Place the client in a horizontal position. B. Roll the client in a blanket to smother the fire. C. Place the client in a vertical position. D. Open a door and encourage air in an enclosed space.

A B

The nurse recognizes that which of the following provide clues about fluid volume status? Select all that apply. A. Hourly urine output B. Daily weights C. Percentage of meals eaten D. Skin turgor E. Oxygen saturation

A B D

A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene? A. Do nothing until the chemical agent is identified. B. Irrigate the wounds with water. C. Wash the wounds with soap and water and apply a barrier cream. D. Insert a 20-gauge I.V. catheter and infuse normal saline solution at 150 ml/hour.

B

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? A. Apply warm compresses over the areas. B. Instruct to pat and not scratch the areas. C. Elevate the extremities above heart level. D. Provide pain medication as needed.

B

A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client? A. Anemia B. Gastric ulcers C. Hyperthyroidism D. Cardiac arrest

B

A client with a burn wound is prescribed mafenide acetate 5% twice daily. Nursing implications associated with this medication include A. monitoring the client for the development of respiratory acidosis. B. premedicating the client with an analgesic prior to application. C. monitoring the client's Na+ and K+ serum levels and replace as prescribed. D. protecting the bed linens and client's clothing from contact to prevent staining.

B

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: A. Epidermal layer only. B. Epidermis and a portion of deeper dermis. C. Entire dermis and subcutaneous tissue. D. Dermis and connective tissue.

B

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? A. Hemoconcentration B. Hemodilution C. Metabolic acidosis D. Lack of erythropoietin factor

B

A sample consensus formula for fluid replacement recommends that an isotonic solution be administered in the first 24 hours of a burn in the range of 2 to 4 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? A. 1,200 mL B. 2,400 mL C. 3,600 mL D. 4,800 mL

B

During the late stages of healing, which intervention helps a burn wound to heal with minimal scarring? A. Removing eschar from the skin B. Applying continuous-compression wraps C. Wearing clothing to protect the burn from the sun D. Maintaining wound care irrigation

B

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? A. Rule of nines B. Use client's palm size C. Parkland formula D. Lund and Browder burns assessment

B

Which is the primary reason for placing a client in a horizontal position while smothering flames are present? A. To prevent collapse and further injuries B. To keep fire and smoke from airway C. To extinguish flames more quickly D. To promote blood flow to the brain and vital organs

B

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? A. Superficial partial thickness B. Deep partial-thickness C. Full-thickness D. Fourth degree

B

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. A. Last meal eaten B. Pre-burn body weight C. Current list of medications D. Last tetanus immunization E. Current body temperature

B C D E

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? A. 9% B. 18% C. 27% D. 36%

C

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? A. "Are the victims suffering from thermal burns?" B. "How many victims are anticipated for transport?" C. "Are the burns associated with chemicals used in the plant?" D. "Are any of the victims expected to have electrical burns?"

C

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? A. Autografts B. Heterografts C. Homografts D. Xenografts

C

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. "Perhaps the garment should be resized." B. "The garment acts as a skin layer and prevents infection." C. "A snug fit is needed to minimize scarring and to smooth the skin." D. "The garment can be removed for an hour each day."

C

Which of the following is a true statement regarding the purposes of skin grafts? A. Increases evaporative fluid loss. B. Increases potential for infection. C. Reduces scarring and contractures. D. Prolongs recovery

C

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? A. 18% B. 27% C. 30% D. 36%

D

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? A. Face only B. Face, neck, and chest C. Face and neck D. Neck and chest

D

The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories. The nurse recognizes this intervention is to promote A. increased metabolic rate. B. increased glucose demands. C. increased skeletal muscle breakdown. D. decreased catabolism.

D

The nurse receives a client following a serious thermal burn. Which complication will the nurse take action to prevent first? A. Tissue hypoxia B. Infection C. Renal failure D. Hypovolemia

D

Which of the following skin substitutes is a nylon-silicone membrane coated with a protein? A. Mederma B. Integra C. Transcyte D. Biobrane

D