Adult Health Ch. 62

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?"

A client has undergone grafting following a burn injury. The nurse understands that the first dressing change at the site of an autograft is performed how soon after the surgery?

2 to 5 days after surgery

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?

2,400 mL

Which of the following is a true statement regarding the purposes of skin grafts?

Reduces scarring and contractures.

A nurse formulates a nursing diagnosis of Impaired physical mobility for a client with full-thickness burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase?

Related to circumferential eschar

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 applying an occlusive dressing to a burned foot. What position should the foot be placed in after application of the dressing?

Adduction

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

Application of cool water

Initial first aid rendered at the scene of a fire includes preventing further injury through heat exposure. Which intervention could contribute to tissue hypoxia and necrosis and therefore should be avoided?

Application of ice

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

Applying knee splints

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

After being exposed to smoke and flames from a house fire, which assessment finding is most important in determining care of the client?

Presence of soot around nasal passages

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

Pulmonary system

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 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

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 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

Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is:

Hyperkalemia.

Which of the following is to be expected soon after a major burn? Select all that apply.

Hypotension Anxiety Tachycardia

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

Immerse the child's legs in cool water.

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

Morphine sulfate

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 antimicrobials is not commonly used to treat burns?

tetracycline

A client who has sustained burns to the anterior chest and upper extremities is brought to the burn center. During the initial stage of assessment, which nursing diagnosis is primary?

Risk for Impaired Gas Exchange

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.

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 recognizes that which of the following provide clues about fluid volume status? Select all that apply.

Skin turgor Daily weights Hourly urine output

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)

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

An explosion of a fuel tanker has resulted in melting of clothing on the driver and extensive full-body burns. The client is brought into the emergency department alert, denying pain, and joking with the staff. Which is the best interpretation of this behavior?

The client has experienced extensive full-thickness burns.

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

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 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.

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%

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 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 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%

Which is the primary nursing intervention in the care of a client with burns exceeding 20% of total body surface area?

Fluid resuscitation

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 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 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)

Which type of debridement occurs when nonliving tissue sloughs away from uninjured tissues?

Natural

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 to 1 mL/kg/hour.

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.

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

decreased catabolism.

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 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 (third degree)

A client who has been burned significantly is taken by air ambulance to the burn unit. What physiologic process furthers a burn injury?

inflammatory