ATI Burn Quiz

A nurse in an emergency department is assessing a client who has extensive burns, including on her face. Which of the following assessments should the nurse perform first?

Characteristics of the cough and sputum

The client is admitted with full thickness and partial thickness burns to more than 30% of the body. The nurse is concerned with the clients nutritional status. Which intervention should the nurse implement?

Encourage the clients family to bring favorite foods

A nurse is planning care for an adult client who sustained severe burn injuries. Which of the following intervention should the nurse include in the plan of care? Select all that apply

-limit visitors in the client's room -increase protein intake -restrict fresh flowers in the room

A client is being seen in the dermatology clinic for a follow up appointment for a second grateful thickness burn. What are characteristics of second-degree burns? Select all that apply

-painful -blistered -mottled, pink red

A client sustains a burn injury to the entire right and left arms, the right leg, and the anterior thorax. According to the rule of nines, the nurse would assess that this injury constitutes which body percentage?

54%

A 60-kg client has sustained third-degree burns over 40% of the body. Using the Parkland (Baxter) formula, the minimum fluid requirements are which during the first 24 hours after the burn?

9600 mL of Lactated Ringer's solution

An adult man has been brought to the emergency department with severe electrical burns. Which assessment finding leads the providers to suspect the brain has been damaged with this burn?

confusion, memory loss, and lethargy

The nurse is reviewing the laboratory test results for a client admitted to the burn unit three hours after an explosion that occurred at a worksite. The client has a severe burn injury that covers 35% of the total body surface area (TBSA). The nurse is most likely to note which finding on the laboratory report?

hematocrit 60% (0.60)

Collagenase is prescribed for a client with a severe burn to the hand. The home care nurse provides instructions to the client regarding the use of the medication. Which client statement indicates an accurate understanding of the use of this medication?

"I will apply the ointment once a day and cover it with a sterile dressing."

The client is scheduled to have a xenograft to a left lower-leg burn. The client asks the nurse "What is a xenograft?" Which statement by the nurse would be the best response?

"The graft will come from an animal, probably a pig."

The nurse is providing care for a client who sustained burns over 30% of the body from a fire. On assessment, the nurse notes that the client is edematous in both burned and unburned body areas. The clients wife asks why her husband "looks so swollen." What is the nurses best response

"leaking blood vessels have led to decreased protein amounts in the blood."

Silver sulfadiazine is prescribed for a client with a partial thickness burn, and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments?

"the medication is likely to cause stinging every time it is applied."

A client is admitted to the hospital of first and second-degree burns. Which assessment findings are associated with first-degree burns? Select all that apply

-painful -red or pink

A nurse is assessing a client who sustained deep partial-thickness and full-thickness burns over 40% of the body 24 hours ago. Which of the following findings are common during the phase? Select all that apply

-temperature 36.1 degrees celsius (97 degrees Fahrenheit) -hyperkalemia -hyponatremia

An adult client with a burn injury just arrived at the emergency department. Place the nursing actions in the care of this client in order of priority. All options must be used

1-assess for airway patency 2-administer oxygen as prescribed 3-obtain vital signs 4-keep the client warm 5-initiate an intravenous (IV) line and begin fluid replacement as prescribed 6-elevate the extremities

The ED nurse is caring for a client admitted with extensive deep partial thickness and full thickness burns. Which intervention should the nurse implement? List in order of priority

1-determine the client's airway status 2-insert two (2) 18-gauge catheters and being fluid replacement 3-apply sterile saline dressings to the burned areas 4-estimate the amount of burned area using the rule of nines 5-administer morphine sulfate, a narcotic analgesic, IV

A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the client?

100% oxygen via a tight-fitting, nonrebreather face mask

A client sustained a burn injury at 7:00 AM. The client spouse states that before the burn, the clients body weight was 198 pounds. The primary healthcare provider has estimated the total body surface area burned is 83%. Using the Parkland (Baxter) formula (4 mL x kilograms of body mass x percent of total BSA), the nurse determines that the total amount of intravenous lactated Ringer's solution that the client will receive by 3 PM of the same day on which the burn occurred is which value? Fill in the blank

14,940 mL 198 lbs = 90 kg 4 x 90 x 83 = 29,880 mL divided by 2 = 14,940 mL

An adult client trapped in a burning house has suffered burns to the back of the head, the upper half of the posterior trunk, and the back of both arms. Using the rule of nines, what percentage does the nurse determine the extent of the burn injury will be? Fill in the blank

22.5% The posterior side of the head equals 4.5%, the back of both arms equals 9%, and the upper half of the posterior trunk equals 9%, totaling 22.5%

Your patient has partial- and full-thickness burn injuries to his anterior chest, anterior abdomen, and entire right arm. Using the Rule of Nines, the percentage of total BSA involved can be estimated at

27%

An adult client was burned in an explosion. The burn initially affected the clients entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The clients clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury?

36%

The nurse is supervising a nursing student who is delivering care to a client with a burn injury to the chest. Nitrofurazone is prescribed to be applied to the side of injury. The nurse should intervene if the student planned to implement which action to apply the medication?

Apply saline-soaked dressings over the medication

The nurse is performing an assessment on a client who sustained circumferential Burns of both legs. Which assessment would be the initial priority and caring for this client?

Assessing peripheral pulses

The camp nurse asked the children preparing to swim in the lake if they have a plied sunscreen. The nurse remind the children that chemical sunscreens are most effective when applied at which times?

At least 30 minutes before exposure to the sun

A client is diagnosed with a full thickness burn. What should the nurse anticipate will be used for final coverage of the clients burn wound?

Autograft

The nurse writes the nursing diagnosis "impaired skin integrity related to open burn wounds." Which intervention would be appropriate for this nursing diagnosis

Clean the clients wounds, body, and hair daily

A client with a burn injury is applying mafenide acetate cream to the wound. The client calls the primary healthcare providers office and tells the nurse that the medication is uncomfortable and it's causing a burning sensation. The nurse should instruct the client to take which action?

Continue with the treatment, as this is expected

The community health nurse is providing a teaching session to firefighters in a small community regarding care of a burn victim at the scene of injury. The nurse instructs the firefighters that in the event of a tar burn, which is the immediate action?

Cooling the injury with water

The nurse is caring for a client with a severe burn who is scheduled for an autographed to be placed on the lower extremity. The nurse creates a postoperative plan of care for the client and should include which intervention in the plan?

Elevate and immobilize the grafted extremity

The nurse is caring for a client who sustained superficial partial thickness burns on the anterior lower legs and anterior thorax. Which findings as a nurse expect to note during the resuscitation/emergent phase of the burn injury?

Elevated hematocrit levels

A client comes in with a sunburn. Which term best describes the sunburn?

First-degree burn

The nurse is caring for a client following an autographed and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client?

Immobilization of the affected leg

A nurse is caring for a client who has sustained burns over 35% of total body surface area. The clients voice has become hoarse, a brassy cough has developed, and the client is drooling. The nurse should identify these findings is indication that the client has which of the following?

Inhalation injury

A nurse is planning care for a client who has deep partial thickness and full thickness thermal burns over 40% of his total body surface and is in the acute phase of burn injury. Which of the following interventions should the nurse include in the plan?

Initiate range of motion exercises

During the fluid accumulation phase of a major burn injury, fluid shift from the:

Intravascular space to the interstitial space

A nurse is caring for a client who has a prescription for silver sulfadiazine cream to be applied to her burn wounds. The nurse should evaluate the client for which of the following laboratory findings?

Leukopenia

The nurse is caring for a client who sustained a thermal burn caused by the inhalation of steam 24 hours ago. The nurse determines that the priority nursing action is to assess which item?

Lung sounds

A nurse is caring for a client who has full-thickness burns covering 63% of her body and smoke inhalation. Which of the following nursing actions is top priority?

Monitor respiratory status

The nurse is developing a nursing care plan for a client with a circumferential burn injury of the right arm. What is the nurses priority action?

Monitor the radial pulse every hour

The nurse is applying mafenide acetate (Sulfamylon), a sulfa antibiotic cream, to a clients lower extremity burn. Which assessment data would require immediate attention by the nurse?

The client's ABGs are pH 7.34, PaO2 38, and HCO3 20 these findings indicate metabolic acidosis and therefore require immediate attention

The nurse is caring for a client with deep partial thickness and full thickness burns to the chest area. Which assessment data would warrant notifying the healthcare provider?

The clients urinary output is 50 mL in 2 hours

The nurse is caring for a client who is admitted to the burn unit after sustaining a burn injury covering 30% of the body. What is the most appropriate timeframe for the emergent phase?

The period from the time the bird was incurred to the time when the client is considered physiologically stable.

The nurse is monitoring the fluid balance of a client with a burn injury. The nurse determines that the client is less than adequately hydrated if which information is noted during assessment?

Urine specific gravity of 1.032

The nurse manager is observing a new nursing graduate caring for a burn client and protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which unsafe component of protective isolation technique?

Wearing gloves and a gown only one giving direct care to the client

A burn client has been given 1% silver sulfadiazine applied to burns twice a day for the past three days. Which laboratory abnormality indicates that the client is experiencing a side or adverse effect of this medication?

White blood cell count of 3000 mm³

Silver sulfadiazine is prescribed for a client with a burn injury. Which laboratory finding requires the need for follow up by the nurse?

White blood cell count of 3000 mm³

A burn injured client is receiving treatment of topical mafenide acetate to the site of injury. The nurse should monitor the client for which the stomach affect they can occur from the use of this medication?

acidosis

A burn client is receiving treatments of topical mafenide acetate to the side of injury. The nurse monitors the client, knowing that which finding indicates that a systemic affect has occurred?

hyperventilation

The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy?

return of distal pulses

The nurse is administering fluids intravenously as prescribed for a client who sustained superficial partial thickness burn injury of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy?

urine output

The nurse has developed a nursing care plan for a client with a burn injury to implement during the emergent phase. Which priority intervention should the nurse include in the plan of care?

Monitor mental status every hour

The client has full thickness burns to 65% of the body, including the chest area. After establishing a patent airway, which collaborative intervention is priority for the client?

Replace fluids and electrolytes

The nurse is evaluating fluid resuscitation attempts in the burn client. Which finding indicates adequate fluid resuscitation?

heart rate of 95 beats/min

A nurse is preparing to administer fentanyl to a client who sustained deep partial thickness and full thickness burns over 60% of the body 24 hours ago. The nurse should plan to use which of the following routes to administer the medication?

intravenous

The client with full thickness burns to 40% of the body, including both legs, is being transferred from a community hospital to a burn center. Which measure should be instituted before the transfer?

Adequate peripheral circulation to both feet ensured

Hypovolemia usually occurs during which major burn phase?

Fluid accumulation

The nurse is caring for a client with full-thickness circumferential burns of the entire trunk of the body who is on a mechanical ventilator. Which finding suggests that an escharotomy may be necessary?

High pressure alarm keeps sounding on the ventilator

Mafenide acetate is prescribed for a client with a burn injury to the hand. Which should the nurse include in the instructions to the client regarding the use of this medication?

It is normal to experience local discomfort and stinging and burning after the medication is applied.

The client sustained a hot grease burn to the right hand and calls emergency room for advice. Which information should the nurse provide to the client?

Place the hand in cool water

The industrial nurse is providing instructions to a group of employees regarding care to a client in the event of a chemical burn injury. The nurse instructs the employees that which is the first consideration in immediate care?

Removing all clothing, including gloves, shoes, and any undergarments

The client is admitted to the burn unit and prescribed pantoprazole (Protonix), a proton pump inhibitor (PPI). Which statement best supports the scientific rationale for administering this medication to a client with a severe burn?

This medication will help prevent a stress ulcer

A client has sustained serious first degree, second degree, and third degree burns in a fire. Which best describes this full-thickness burn and the burned area that involves subcutaneous tissue, muscle, and bone?

Third-degree burn

A nurse is caring for a client who has burn injuries on his trunk. The nurse is explaining what to expect from the prescribe Hydro therapy. Which of the following statements by the client indicates an understanding of the teaching?

"I will be on a special shower table."

A nurse is caring for an adolescent client who has burn wounds on her face and hands. Which of the following statements by the client indicates that she has adapted to her changed body image?

"May I go with my family to the visitor's lounge?"

The nursing educator has just completed a lecture to a group of nurses regarding care of the client with a burn injury. A major aspect of the lecture was care of the client at the scene of a fire. Which statement, if made by a nurse, indicates a need for further instruction?

"The client should be maintained in a standing position"

A client is brought to the emergency department with partial thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply

-assess for airway patency -administer oxygen as prescribed -elevate extremities if no fractures are present

Which nursing intervention should be included for the client who has full thickness and deep partial thickness burns to 50% of the body? Select all that apply

-perform meticulous hand hygiene -use sterile gloves for wound care -wear gown and mask during procedures -administer antibiotic as prescribed

You insert an IV line and begin fluid resuscitation. The doctor wants you to use the parkland formula. The patient is 155 pounds (70-kg) Mail and is estimated at having 50% of his total body surface area burned. What amount of lactated ringer's solution should you administer over the first 8 hours?

7,000 mL 4 ml x 50 x 70= 14,000 mL in first 24 hours 14,000 / 2 = 7,000 mL

The nurse is performing an assessment on a client admitted to the nursing unit who is sustained an extensive burn injury involving 45% of total body surface area. When planning for fluid resuscitation, the nurse should consider that fluid shifting to these interstitial spaces is greatest during which time period?

Between 18 and 24 hours after the injury

During the fluid remobilization phase of a patient with burn injuries, the nurse would expect to see signs of which electrolyte in balance?

Hypokalemia

A client who is being evaluated for thermal burn injuries to the arms and legs complains of thirst and asks the nurse for a drink. Which action by the nurse is most appropriate?

Keep the client on NPO (nothing by mouth) status

Which clinical manifestation would lead the health care provider to diagnose the sunburn as severe?

There is blistering of he skin and associated fever and chills.

A nurse is evaluating the laboratory values of a client who is in the resuscitation phase following a major burn. Which of the following laboratory findings should the nurse expect?

Sodium 132 mEq/L

A nurse in a providers office is assessing a client who has a severe sunburn. Which of the following classifications for the nurse use to document this burn?

Superficial thickness

The client is being discharged after being in the burn unit for six weeks. Which strategies should the nurse identify to promote the clients mental health?

Tell the client to remember the changes in lifestyle take time

A nurse is assessing a client who sustained superficial partial thickness and deep partial thickness burns 72 hours ago. Which of the following findings should the nurse report to the provider?

Temperature of 39.1 degrees Celsius (102.4 F)

A client is admitted to the hospital a second-degree burns over 30% of the body. What is a characteristic of second-degree burns?

They involve the dermis and the epidermis

The client comes into the emergency room in severe pain and reports that a pot of boiling hot water accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin and both feet are a edematous. Which depth of burn should the nurse document?

deep partial thickness

A client is admitted to the hospital emergency department after receiving a burn injury in a house fire. The skin on the clients trunk is tan, dry, and hard. It is edematous but not very painful. The nurse determines that his clients burn should be classified as which type?

full-thickness

The emergency department nurse is caring for a client who has sustained chemical burns to the esophagus after ingestion of lye. The nurse reviews the primary healthcare provider's prescriptions and should plan to question which prescription?

gastric lavage

The intensive care unit neighbor nurse is developing a nursing care plan for a client with severe full thickness and deep partial thickness burns over half the body. Which of the client problems has priority?

high risk for infection

The nurse is planning care for a client who suffered a burn injury and has a negative self-image related to keloid formation at the burn site. The keloid formation is indicative of which condition?

hypertrophy of collagen fibers

A client is undergoing fluid replacement after being burned and 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mm Hg, a pulse rate of 110 bpm, and a urine output of 20 mL over the past hour. The nurse reports the findings to the primary healthcare provider (PHCP) and anticipates which prescription?

increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour

A client is seen in the ambulatory care clinic for a superficial burn to the arm. On assessing the skin at the burn injury, what will the nurse observe?

pink or red color

A nurse is teaching a client who has extensive deep partial- and full- thickness burns and requires a topical antimicrobial medication. The goal of this medication therapy is to reduce which of the following outcomes?

Bacterial growth

A client sustained a burn from cutaneous exposure to lye. At the site of injury, copious irrigation to the site was performed for one hour. On admission to the hospital emergency department, the nurse assesses the burn site. Which findings would indicate that the chemical burn process is continuing?

liquefication necrosis