BURN

An unconscious client with multiple injuries arrives in the emergency department. Which nursing intervention receives the highest priority? 1. Establishing an airway. 2. Replacing blood loss. 3. Stopping bleeding from open wounds. 4. Checking for a neck fracture.

1. The highest priority for a client with multiple injuries is to establish an open airway for effective ventilation and oxygenation. Unless the client has a patent airway, other care measures will be futile. Replacing blood loss, stopping bleeding from open wounds, and checking for a neck fracture are important nursing interventions to be completed after the airway and ventilation are established.

Using the Parkland formula, calculate the hourly rate of fluid replacement with lactated Ringer's solution during the first 8 hours for a client weighing 75 kg with total body surface area (TBSA) burn of 40%. _______________ mL/ hour.

750 mL/hour. Lactated Ringer's solution 4 mL × weight in kg × TBSA; half given over the first 8 hours and half given over the next 16 hours.

The rate at which IV fluids are infused is based on the burn client's: A) Lean muscle mass and body surface area (BSA) burned. B) Total body weight and BSA burned. C) Total BSA and BSA burned. D) Height and weight and BSA burned.

B During the first 24 hours, fluid replacement for an adult burn client is based on total body weight and BSA burned. Lean muscle mass considers only muscle mass; replacement is based on total body weight . Total surface area is estimated by taking into account the individual's height and weight.

A nurse is assessing a client with increasing intracranial pressure. What is a client's mean arterial pressure (MAP) in mm Hg when blood pressure (BP) is 120/60 mm Hg? _______________mm Hg. 80mm Hg To obtain the MAP, use this formula: MAP = [systolic BP + (2 x diastolic BP)] ÷ 3 MAP = [120 + (2 x 60)] ÷ 3 MAP= 240 ÷ 3 = 80 A client with a contusion has been admitted for observation following a motor vehicle accident when he was driving his wife to the hospital to deliver their child. The next morning, instead of asking about his wife and baby, he asked to see the football game on television that he thinks is starting in 5 minutes. He is agitated because the nurse will not turn on the television. Whatshould the nurse do next? Select all that apply. 1. Find a television so the client can view the football game. 2. Determine if the client's pupils are equal and react to light. 3. Ask the client if he has a headache. 4. Arrange for the client to be with his wife and baby. 5. Administer a sedative.

2, 3 The nurse should determine if the client's pupils are equal and react to light, and ask the client if he has a headache. Confusion, agitation, and restlessness are subtle clinical manifestations of increased intracranial pressure (ICP). At this time, it is not appropriate for the nurse to find a television or arrange for the client to see his wife and baby. Administering a sedative at this time will obscure assessment of increased ICP.

A client is receiving fluid replacement with lactated Ringer's after 40% of the body was burned 10 hours ago. The assessment reveals temperature 36.2 ° C, heart rate 122 , blood pressure 84/ 42, Central venous pressure (CVP) 2 mm Hg, and urine output 25 mL for the last 2 hours. The IV rate is currently at 375 mL /h. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the health care provider with a recommendation for: A) Furosemide (Lasix). B) Fresh frozen plasma. C) IV rate increase. D) Dextrose 5%.

C The decreased urine output, low blood pressure, low CVP, and high heart rate indicate hypovolemia and the need to increase fluid volume replacement. Furosemide is a diuretic that should not be given due to the existing fluid volume deficit. Fresh frozen plasma is not indicated. It is given for clients with deficient clotting factors who are bleeding . Fluid replacement used for burns is lactated Ringer's solution, normal saline, or albumin.

In the acute phase of burn injury, which pain medication would most likely be given to the client to decrease the perception of the pain? A) Oral analgesics such as ibuprofen (Motrin) or acetaminophen (Tylenol). B) Intravenous opioids. C) Intramuscular opioids. D) Oral antianxiety agents such as lorazepam (Ativan).

B The severe pain experienced by burn clients requires opioid analgesics. In addition, opioids such as morphine sedate and alleviate apprehension. Oral analgesics such as ibuprofen or acetaminophen are unlikely to be strong enough to effectively manage the intense pain experienced by the client who is severely burned. Because of the altered tissue perfusion from the burn injury, intravenous medications are preferred . Antianxiety agents are not effective against pain.

Which of the following clients with burns will most likely require an endotracheal or tracheostomy tube? A client who has: 1. Electrical burns of the hands and arms causing arrhythmias. 2. Thermal burns to the head, face, and airway resulting in hypoxia 3. Chemical burns on the chest and abdomen. 4. Secondhand smoke inhalation.

B. Airway management is the priority in caring for a burn client. Tracheostomy or endotracheal intubation is anticipated when significant thermal and smoke inhalation burns occur. Clients who have experienced burns to the face and neck usually will be compromised within 1 to 2 hours. Electrical burns of the hands and arms, even with cardiac arrhythmias, or a chemical burn of the chest and abdomen is not likely to result in the need for intubation. Secondhand smoke inhalation does influence an individual's respiratory status but does not require intubation unless the individual has an allergic reaction to the smoke.

After the initial phase of the burn injury, the client's plan of care will focus primarily on: A) Helping the client maintain a positive self-concept. B) Promoting hygiene. C) Preventing infection. D) Educating the client regarding care of the skin grafts.

C The inflammatory response begins when a burn is sustained. As a result of the burn, the immune system becomes impaired. There are a decrease in immunoglobulins, changes in white blood cells, alterations of lymphocytes, and decreased levels of interleukin. The human body's protective barrier, the skin, has been damaged. As a result, the burn client becomes vulnerable to infections. Education and interventions to maintain a positive self-concept would be appropriate during the rehabilitation phase. Promoting hygiene helps the client feel comfortable; however, the primary focus is on reducing the risk for infection.

The client with a major burn injury receives total parenteral nutrition (TPN). The expected outcome is to: A) Correct water and electrolyte imbalances. B) Allow the gastrointestinal tract to rest. C) Provide supplemental vitamins and minerals. D) Ensure adequate caloric and protein

D Nutritional support with sufficient calories and protein is extremely important for a client with severe burns because of the loss of plasma protein through injured capillaries and an increased metabolic rate . Gastric dilation and paralytic ileus commonly occur in clients with severe burns, making oral fluids and foods contraindicated. Water and electrolyte imbalances can be corrected by administration of IV fluids with electrolyte additives, although TPN typically includes all necessary electrolytes. Resting the gastrointestinal tract may help prevent paralytic ileus, and TPN provides vitamins and minerals ; however, the primary reason for starting TPN is to provide the protein necessary for tissue healing.

Which of the following activities should the nurse include in the plan of care for a client with burn injuries to be carried out about one-half hour before the daily whirlpool bath and dressing change? A) Soak the dressing. B) Remove the dressing. C) Administer an analgesic. D) Slit the dressing with blunt scissors.

C Removing dressings from severe burns exposes sensitive nerve endings to the air, which is painful. The client should be given a prescribed analgesic about one-half hour before the dressing change to promote comfort. The other activities are done as part of the whirlpool and dressing change process and not one-half hour beforehand.

A client is admitted to the hospital after sustaining burns to the chest, abdomen , right arm, and right leg. The shaded areas in the illustration indicate the burned areas on the client's body. Using the "rule of nines," estimate what percentage of the client's body surface has been burned. A) 18%. B) 27%. C) 45%. D) 64%.

C According to the rule of nines, this client has sustained burns on about 45% of the body surface. The right arm is calculated as being 9%, the right leg is 18%, and the anterior trunk is 18%, for a total of 45%.

During the emergent (resuscitative)phase of burn injury, which of the following indicates that the client is requiring additional volume with fluid resuscitation? A) Serum creatinine level of 2.5 mg/ dL (221 μmol/ L). B) Little fluctuation in daily weight. C) Hourly urine output of 60 mL. D) Serum albumin level of 3.8 (38 g/ L).

A. Fluid shifting into the interstitial space causes intravascular volume depletion and decreased perfusion to the kidneys. This would result in an increase in serum creatinine. Urine output should be frequently monitored and adequately maintained with intravenous fluid resuscitation that would be increased when a drop in urine output occurs. Urine output should be at least 30 mL/ h. Fluid replacement is based on the Parkland or Brooke formula and also the client's response by monitoring urine output, vital signs, and CVP readings. Daily weight is important to monitor for fluid status. Little fluctuation in weight suggests that there is no fluid retention and the intake is equal to output. Exudative loss of albumin occurs in burns, causing a decrease in colloid osmotic pressure. The normal serum albumin is 3.5 to 5 g/ dL (35 to 50 g/ L).

During the early phase of burn care, the nurse should assess the client for? A) Hypernatremia. B) Hyponatremia. C) Metabolic alkalosis. D) Hyperkalemia.

D. Immediately after a burn, excessive potassium from cell destruction is released into the extracellular fluid. Hyponatremia is a common electrolyte imbalance in the burn client that occurs within the first week after being burned. Metabolic acidosis usually occurs as a result of the loss of sodium bicarbonate.

The nurse is caring for a client with severe burns who is receiving fluid resuscitation. Which of the following indicates that the client is responding to the fluid resuscitation? A) Pulse rate of 112. B) Blood pressure of 94/ 64. C) Urine output of 30 mL/ h. D) Serum sodium level of 136 mEq/ L (136 mmol/ L).

C Ensuring a urine output of 30 to 50 mL/ h is the best measure of adequate fluid resuscitation. The heart rate is elevated, but is not an indicator of adequate fluid balance. The blood pressure is low, likely related to the hypervolemia, but urinary output is the more accurate indicator of fluid balance and kidney function. The sodium level is within normal limits.