Burns 2040 Chapter 26
Which factors indicate that a client's burn wounds are becoming infected? Select all that apply. A Dry, crusty granulation tissue B Elevated blood pressure C Hypoglycemia D Edema of the skin around the wound E Tachycardia
A,D,E
NORMAL hematocrit in males is?
40%
4. A client who was rescued from an explosion is provided fluid resuscitation. Which factor should be assessed in the client after providing fluid resuscitation? A Serum sodium levels B Hemoglobin levels C Alanine aminotransferase D Serum cholesterol levels
A
A client has just undergone arterial revascularization. Which statement by the client indicates a need for further teaching related to postoperative care? A "My leg might turn very white after the surgery." B "I should be concerned if my foot turns blue." C "I should report a fever or any drainage." D "Warmness, redness, and swelling are expected."
A
An escharotomy must be performed in a client admitted for burns. Which statement accurately describes this procedure? A An incision is made through the burn eschar. B Anesthesia is administered to the client for pain. C Analgesia is not administered with this procedure. D The procedure is performed in the surgical suite.
A
How are topical antibiotics using an open technique applied to minor burns? A The medication is applied on the burn without the dressing. B The wound is cleaned every 48 to 72 hours. C The wound is cleaned with hot water. D The medication is applied without the use of cotton.
A
To position a client's burned upper extremities appropriately, how does the nurse position the client's elbow? A In a neutral position B In a position of comfort C Slightly flexed D Slightly hyperextended
A
What intervention will the nurse implement to reduce a client's pain after a burn injury? A Administering morphine 4 mg intravenously. B Administering hydromorphone (Dilaudid) 4 mg intramuscularly. CC Applying ice to the burned area DAvoiding tactile stimulation
A
When teaching fire safety to parents at a school function, which advice does the school nurse offer about the placement of smoke and carbon monoxide detectors? A "Every bedroom should have a separate smoke detector." B "Every room in the house should have a smoke detector." C "If you have a smoke detector, you don't need a carbon monoxide detector." D "The kitchen and the bedrooms are the only rooms that need smoke detectors."
A
Which of the following skin grafts are obtained from human cadavers? A Allograft B Heterograft C Xenograft D Porcine
A
Why is positive end-expiratory pressure (PEEP) provided to the clients with major burns? A To increase the lung volume B To decrease the exchange of gases C To increase the vascular supply D To increase the respiratory rate
A
The nurse is evaluating the effectiveness of fluid resuscitation for a client in the resuscitation phase of burn injury. Which finding does the nurse correlate with clinical improvement? A Blood urea nitrogen (BUN), 36 mg/dL B Creatinine, 2.8 mg/dL C Urine output, 40 mL/hr D Urine specific gravity, 1.042
C
A client arrives in the emergency department with burns as a result of spilling boiling water while cooking. Which assessment finding of the burned areas on the tops of both hands and chest does the nurse use as a basis to document a probable full-thickness injury? A Most of the wounded area is red. B Thrombosed blood vessels are visible beneath the skin surface. C The area does not blanch when firm pressure is applied. D The client reports that the area hurts when touched.
B
A client is in the resuscitation phase of burn injury. Which route does the nurse use to administer pain medication to the client? A Intramuscular B Intravenous C Sublingual D Topical
B
A client received a burn due to contact with hydrochloric acid. The burn is brown in color with severe edema and absence of blisters. Which category of burn does the client have? A Superficial burn B Full- thickness burn C Deep full- thickness burn E Deep partial- thickness burn
B
A client with a burn injury due to a house fire is admitted to the burn unit. The client's family asks the nurse why the client received a tetanus toxoid injection on admission. What is the nurse's best response to the client's family member? A "The last tetanus injection was less than 5 years ago." B "Burn wound conditions promote the growth of Clostridium tetani." C "The wood in the fire had many nails, which penetrated the skin." D "The injection was prescribed to prevent infection from pseudomonas."
B
An older client has suffered a 45% body surface area burn from a house fire. Which complication is the client at greater risk of developing because of age-related changes? A Ineffective pain management B Acute kidney injury C Anxiety D Gastric stress ulcers
B
During the resuscitation postburn phase, which route is used to administer morphine for pain relief? A Intramuscular B Intravenous C Subcutaneous D Oral
B
How long must a client with burns wear pressure garments after undergoing biological dressing? A Once per week B 24 hours per day C Daily for a month D Three hours per day
B
In cases of burn injury, why do the eyelids, ears, and nose tend to sustain deeper burns than other areas of the body? A These areas have a greater number of pain receptors. B These areas have comparatively thinner skin. C These areas receive a lesser blood supply. D These areas have a lesser number of sweat glands.
B
The client with a dressing covering the neck is experiencing some respiratory difficulty. What is the nurse's best first action? A Administer oxygen. B Loosen the dressing. C Notify the emergency team. D Document the observation as the only action.
B
The nurse on a burn unit has just received a change-of-shift report about these clients. Which client does the nurse assess first? A Adult client admitted a week ago with deep partial-thickness burns over 35% of the body who is reporting pain B Firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers, "I can't catch my breath!" C An electrician who suffered external burn injuries a month ago and is asking the nurse to contact the health care provider immediately about discharge plans D Older adult client admitted yesterday with partial- and full-thickness burns over 40% of the body who is receiving IV fluids at 250 mL/hr
B
Increased urine specific gravity may be due to conditions such as?
Burns - During the fluid shift, blood flow to the kidney may not be adequate for filtration. As a result, urine output is greatly decreased compared with IV fluid intake. The urine is very concentrated and has a high specific gravity.
A client who was the sole survivor of a house fire says, "I feel so guilty. Why did I survive?" What is the best response by the nurse? A "Do you want to pray about it?" B "I know, and you will have to learn to adapt to a new body image." C "Tell me more." D "There must be a reason."
C
Tissue destruction from burns results from?
Coagulation Protein denaturation Ionization of cellular contents
A client is in the acute phase of burn injury. For which action does the nurse decide to coordinate with the registered dietitian? A Discouraging having food brought in from the client's favorite restaurant B Providing more palatable choices for the client C Helping the client lose weight D Planning additions to the standard nutritional pattern
D
During the acute phase, the nurse applied gentamicin sulfate (topical antibiotic) to the burn before dressing the wound. The client has all the following manifestations. Which manifestation indicates that the client is having an adverse reaction to this topical agent? A Increased wound pain 30 to 40 minutes after drug application B Presence of small, pale pink bumps in the wound beds C Decreased white blood cell count D Increased serum creatinine level
D
Three days after a burn injury, the client develops a temperature of 100° F, white blood cell count of 15,000/mm3, and a white, foul-smelling discharge from the wound. The nurse recognizes that the client is most likely exhibiting symptoms of which condition? A Acute phase of the injury B Autodigestion of collagen C Granulation of burned tissue D Wound infection
D
circumoral burns
surrounding the mouth
NORMAL hematocrit in females is?
45%
A client who was rescued from an explosion is provided fluid resuscitation. Which factor should be assessed in the client after providing fluid resuscitation? A Serum sodium levels B Hemoglobin levels C Alanine aminotransferase D Serum cholesterol levels
A
A newly admitted client has deep partial-thickness burns. The nurse expects to see which clinical manifestations? A Painful red and white blisters B Painless, brownish-yellow eschar C Painful reddened blisters D Painless black skin with eschar
A
Describe pain management of the burned client.
Administer pain medication, especially prior to dressing wound (usually Morphine 10 mg). Teach distraction/relaxation techniques. Teach use of guided imagery.
A client with burns has developed sepsis. Which sign or symptom in the client indicates fungal infection? A Severe disorientation B Occasional diarrhea C Hypothermia D Lethargy
B
A client with burns to the face, neck, upper body, and hands from a house fire starts wheezing on exhalation and reports difficulty swallowing about 4 hours after the injury. What is the nurse's best first action? A Ensure that the client remains NPO. B Apply oxygen and notify the Rapid Response Team. C Slow the IV infusion rate. D Raise the head of the bed.
B
A client's jeans caught on fire while camping, inflicting deep partial-thickness burns to the anterior and posterior surface of both legs. Using the rule of nines, what percent body surface area does the nurse estimate the client's burn to be? A 9% B 18% C 36% D 40%
C
How does the nurse determine accurate calorie requirements for a client with burns? A Calculating the body mass index regularly B Measuring body weight regularly C Using indirect calorimetry D Using the Parkland formula
C
The RN has assigned a client who has an open burn wound to the LPN. Which instruction is most important for the RN to provide the LPN? A Administer the prescribed tetanus toxoid vaccine. B Assess wounds for signs of infection. C Encourage the client to cough and breathe deeply. D Wash hands on entering the client's room.
D
Critical systems affected by burns include?
Respiratory Integumentary Cardiovascular Renal GI Neurologic
Hourly urine output is?
0.5 mL/kg (about 30 mL/hr)
Which method is used in assessing the measurement of burns in a client whose weight and height are in proportion? A Body area is divided into multiples of 9% B Body area is divided into multiples of 12% C Body area is divided into multiples of 5% D Body area is divided into multiples of 20%
A
Which nursing intervention is likely to be most helpful in providing adequate nutrition while the client is recovering from a thermal burn injury? A Allowing the client to eat whenever he or she wants B Beginning parenteral nutrition high in calories C Limiting calories to 3000 kcal/day D Providing a low-protein, high-fat diet
A
Which physiologic effect may indicate mild carbon monoxide poisoning? A Decreased visual acuity B Decreased blood pressure C Cardiopulmonary instability D Altered mental state
A
Which statement indicates that a client with facial burns understands the need to wear a facial pressure garment? A "My facial scars should be less severe with the use of this mask." B "The mask will help protect my skin from sun damage." C "This treatment will help prevent infection." D "Using this mask will prevent scars from being permanent."
A
Which statement made by a client who experienced 45% total body surface area burns to the face, neck, chest, and arms indicates positive adjustment to the injury? A "I am planning on returning to work gradually so that I don't get too tired." B "I am working with my family so they can do all of the chores I used to do." C "I hope the home care nurse can change my dressings so that I do not have to look at my wounds." D "My wife and I have decided to go to movies instead of baseball games so that people can't see me."
A
What is indirect calorimetry?
This method assesses energy expenditure by measuring oxygen consumption and carbon dioxide production. Measurements are taken while the patient is at rest—usually at least 30 minutes after the most recent dressing changes or other stressful procedures.
What is the most common and most sensitive noninvasive assessment parameter for cardiac output and tissue perfusion.
Urine output
Describe an autograft
Use of client's own skin for grafting
Describe an autograft.
Use of client's own skin for grafting.
Why is the burned client allowed NO "free" water?
Water may interfere with electrolyte balance. Client needs to ingest food products with highest biological value.
Which is the priority nursing diagnosis during the first 24 hours for a client with chemical burns to the legs and arms that are red in color, edematous, and without pain? A Decreased Tissue Perfusion B Disturbed Body Image C Risk for Disuse Syndrome D Risk for Ineffective Breathing Pattern
A
What is normal Urine specific gravity?
1.005 to about 1.030
Which electrolyte abnormality does the nurse anticipate during the resuscitation phase in a client with burn injury? A Hyperkalemia B Hypernatremia C Hypochloremia D Hypoglycemia
A
A client spilled a large open frying pan of hot cooking grease and received burns to the entire anterior chest and abdomen, the entire anterior section of the left arm, and the anterior portion of the left leg from the groin to the knee. At what percentage of total body surface area does the nurse calculate the injury using the rule of nines? A 25% to 27% B 30% to 31% C 33% to 45% D 40% to 42%
A
A client with 32% total body surface area burns has a hematocrit of 54% 10 hours after the burn injury and 8 hours after fluid resuscitation was started. What is the nurse's best action? A Assess the client's blood pressure and urine output. B Notify the health care provider immediately. C Evaluate the client's electrocardiogram for dysrhythmias. D Increase the IV infusion rate.
A
A client with burn injuries states, "I feel so helpless." Which nursing intervention is most helpful for this client? A Encouraging participation in wound care B Encouraging visitors C Reassuring the client that he or she will be fine D Telling the client that these feelings are normal
A
A client with full-thickness burns to the lower extremities has had emergent fasciotomies. What assessment parameter does the nurse monitor to evaluate the effectiveness of the fasciotomies? A Improved distal pulses B Reduced edema C Improved blood pressure D Reduced fluid resuscitation needs
A
A client with partial-thickness burns of the face and chest caused by a campfire is admitted to the burn unit. The nurse plans to carry out which health care provider request first? A Give oxygen per face mask. B Infuse lactated Ringer's solution at 150 mL/hr. C Give morphine sulfate 4-10 mg IV for pain control. D Insert a 14 Fr retention catheter
A
A client with peripheral neuropathy is being discharged home after a pacemaker placement. What is the priority question to ask the client in assessing safety for home discharge planning to prevent burn-related injuries? A "Do you know how to ensure the hot water tank is set below 140° F?" B "Can friends provide meals for you for a few days?" C "Tell me how you test bath water before getting into the tub." D "Do you usually wear sunscreen when you are outside?"
A
A client's burn injury was caused by an exposure to pool chemicals. Which laboratory result does the nurse monitor closely for possible signs of organ injury? A Liver function tests B Arterial blood gases C Serum electrolytes D White blood cell count
A
The nurse is caring for a client with a burn injury who is receiving sulfadiazine (Silvadene) to the burn wounds. Which best describes the goal of topical antimicrobials? A Reduction of bacterial growth in the wound and prevention of systemic sepsis B Prevention of cross-contamination from other clients in the unit C Enhanced cell growth D Reduced need for a skin graft
A
The nurse is reviewing a medication record for an older adult client recently admitted to the burn unit with severe burns to the upper body from a house fire. The nurse plans to contact the health care provider if the client is receiving which medication? A Furosemide (Lasix) B Digoxin (Lanoxin) C Dopamine (Inotropin) D Morphine sulfate
A
Which category of burn injury reflects deep partial-thickness burns affecting 20% of the total body surface area (TBSA)? A Moderate burn B Major burn C Minor burn D Severe burn
A
A client who was successfully resuscitated after a burn injury begins diuresis 3 days after admission. For which assessment findings does the nurse observe during this phase of the injury? Select all that apply. A Hyponatremia B Hyperkalemia C Hypotension D Weight gain E Metabolic acidosis F Metabolic alkalosis
A,C,E
What assessment data suggest that a client may have suffered an inhalation injury in addition to a thermal injury from a car explosion? Select all that apply. A Injury occurred in a closed space B Cherry-red cheeks C Burned eyebrows and singed nasal hairs D Reports of thirst E Coughing up carbonaceous sputum F Somnolence
A,C,E
Titration of fluid means?
Adjustment of the IV fluid rate on the basis of urine output plus serum electrolyte values
Several clients have been brought to the emergency department (ED) after an office building fire. Which client is at greatest risk for inhalation injury? A Middle-aged adult who is frantically explaining to the nurse what happened B Young adult who suffered burn injuries in a closed space C Adult with burns to the extremities D Older adult with thick, tan-colored sputum
B
The health care provider has ordered a blood transfusion for a female client with serious electrical burns. What hematocrit level reflects the need for transfusion when symptoms of hypoxia are present? A 28% B 18% C 40% D 36%
B
The nurse is caring for a client with burns to the face. Which statement by the client requires further evaluation by the nurse? A "I am getting used to looking at myself." B "I don't know what I will do when people stare at me." C "I know that I will never look the way I used to, even after the scars heal." D "My spouse does not stare at the scars as much now as in the beginning."
B
The nurse is reviewing the orders for a client admitted with 25% body surface area burns. Which order does the nurse clarify with the health care provider? A Daily weights B Hold omeprazole (Prilosec) C Fentanyl (Actiq) 50 mcg IV every 4 hours PRN for pain D Activity as tolerated
B
Twelve hours after the client was initially burned, bowel sounds are absent in all four abdominal quadrants. Which is the nurse's best action? A Administers a laxative B Documents the finding C Increases the IV flow rate D Repositions the client onto the right side
B
What is the characteristic of a burn caused by brief contact with a hot plate? A Red-white in color B Heals in about 2 weeks C Severe edema D Soft and dry eschar
B
Which alteration observed in a client rescued from a fire indicates pulmonary injury? A Exhaling through the mouth B Inability to swallow fluids C Reporting dizziness D Coughing with sputum
B
Which is the priority nursing intervention for maintaining mobility in a client with burns to the head and neck? A Maintain the client in a supine position for several hours a day. B Do not allow the use of pillows under the head or neck. C Encourage the client to logroll during position changes. D Use foam wedges to maintain trunk alignment
B
Which method must be employed during hydrotherapy for the debridement of a wound in the client with acid burns? A The wound must be cleaned three times a week. B Nonviable tissue must be removed by forceps. C The wounds are rinsed with cold water. D Small blisters are opened with scissors
B
Which wound assessment characteristics suggest a superficial partial thickness burn injury? A Black-brown coloration B Painful C Moderate to severe edema D Absence of blisters
B
A nursing student is caring for a client with open wound burns. Which nursing interventions does the nursing student provide for this client? Select all that apply. A Provides cushions and rugs for comfort B Performs frequent handwashing C Places plants in the client's room D Performs gloved dressing changes E Uses disposable dishes
B,D,E
A burned client newly arrived from an accident scene is prescribed 50 mcg of fentanyl intravenously. What is the most important reason the nurse administers the analgesic by the intravenous (IV) route? A The drug will be effective more quickly than if given intramuscularly or subcutaneously. B It is less likely to interfere with the client's breathing and oxygenation. C The danger of an overdose from rapid absorption once interstitial fluid shifts resolve is reduced. D The client has delayed gastric emptying.
C
A client is admitted with an electrical burn injury from working with telephone lines located close to high-voltage power lines. What is the priority assessment for this client? A Treat pain with intramuscular morphine as prescribed. B Evaluate the client's ability to cough and deep-breathe. C Evaluate the urine volume and color. D Calculate the client's protein intake.
C
In assessing a client in the rehabilitative phase of burn therapy, which priority problem does the nurse anticipate? A Intense pain B Potential for inadequate oxygenation C Reduced self-image D Potential for infection
C
The burned client relates the following history of previous health problems. Which one should alert the nurse to the need for alteration of the fluid resuscitation plan? A Seasonal asthma B Hepatitis B 10 years ago C Myocardial infarction 1 year ago D Kidney stones within the last 6 month
C
The nurse is assessing the wound of a client who was burned while burning leaves in the yard. Which assessment finding of the burned areas on the client's feet, legs, and hands suggests a deep partial-thickness injury? A There are blisters present. B The client reports pain when the area is touched. C The area is red and dry and blanches slowly when firm pressure is applied. D Thrombosed blood vessels are visible beneath the skin surface.
C
The nurse is caring for a client with burns. Which question does the nurse ask the client and family to assess their coping strategies? A "Do you support each other?" B "How do you plan to manage this situation?" C "How have you handled similar situations before?" D "Would you like to see a counselor?"
C
What precautionary measure must individuals take to prevent fires? A While drinking alcohol, smoking must be done in an open area. B Space heaters must be placed on a cotton cloth. C Chimneys must be cleaned once in a year. D One smoke detector must be placed in the house.
C
Which assessment information about a 60-kg client admitted 12 hours ago with a full-thickness burn over 30% of the total body surface area is of greatest concern to the nurse? A Bowel sounds are absent. B The pulse oximetry level is 91%. C The serum potassium level is 6.1 mEq/L. D Urine output since admission is 370 mL.
C
Which assessment is the nurse's highest priority in caring for a client in the acute phase of burn injury? A Bowel sounds B Muscle strength C Signs of infection D Urine output
C
Which clinical manifestation is indicative of wound healing for a client in the acute phase of burn injury? A Pale, boggy, dry, or crusted granulation tissue B Increasing wound drainage C Scar tissue formation D Sloughing of grafts
C
Which finding indicates to the nurse that a client with a burn injury has a positive perception of his appearance? A Allowing family members to change his dressings B Discussing future surgical reconstruction C Performing his own morning care D Wearing the pressure dressings as ordered
C
Which laboratory result, obtained on a client 24 hours post-burn injury, will the nurse report to the physician immediately? A Arterial pH, 7.32 B Hematocrit, 52% C Serum potassium,7.5 mmol/L (mEq/L) D Serum sodium, 131 mmol/L (mEq/L)
C
Which statement best exemplifies the client's understanding of rehabilitation after a full-thickness burn injury? A "I am fully recovered when all the wounds are closed." B "I will eventually be able to perform all my former activities." C "My goal is to achieve the highest level of functioning that I can." D "There is never full recovery from a major burn injury."
C
Which strategies does the nurse include when teaching a college student about fire prevention in the dormitory room? A Use space heaters to reduce electrical costs. B Check water temperature before bathing. C Do not smoke in bed. D Wear sunscreen.
C
Which systemic signs of infection can be seen in the client with burn injuries? A Increase in white blood cell (WBC) count B Hypoglycemia C Altered level of consciousness D Sloughing of grafts
C
Which topical agent is typically used on a burn wound for rapid debridement? A Iodine tincture (Iodopen) B Polymixin B (Polysporin) C Collagenase (Santyl) D Penciclovir (Denavir)
C
When delegating care for clients on the burn unit, which client does the charge nurse assign to an RN who has floated to the burn unit from the intensive care unit? A Burn unit client who is being discharged after 6 weeks and needs teaching about wound care B Recently admitted client with a high-voltage electrical burn C A client who has a 25% total body surface area (TBSA) burn injury, for whom daily wound débridement has been prescribed D Client receiving IV lactated Ringer's solution at 150 mL/hr
D
The client is a burn victim who is noted to have increasing edema and decreased urine output as a result of the inflammatory compensation response. What does the nurse do first? A Administer a diuretic. B Provide a fluid bolus. C Recalculate fluid replacement based on time of hospital arrival. D Titrate fluid replacement.
D
Which finding is characteristic during the emergent period after a deep full thickness burn injury? A Blood pressure of 170/100 mm Hg B Foul-smelling discharge from wound C Pain at site of injury D Urine output of 10 mL/hr
D
Decreased urine specific gravity may be due to conditions such as?
Damage to kidney tubule cells (renal tubular necrosis) Diabetes insipidus Drinking too much fluid Kidney failure
Nutritional status is a major concern when caring for a burned client. List 3 specific dietary interventions sed with burned clients.
High-calorie, high-protein, high-carbohydrate diet. Medications with juice or milk; NO "free" water. Tube feeding at night. Maintain accurate, daily calorie counts. Weigh client daily.
Outline admission care of the burned client.
Provide a patent airway as intubation may be necessary. Determine baseline data. Initiate fluid and electrolyte therapy. administer pain medication. Determine depth and extent of burn. Administer tetanus toxoid. Insert NG tube.
List 4 signs of an inhalation burn.
Singed nasal airs, Changes in voice such as hoarseness or brassy cough circumoral burns; sooty or bloody sputum, hoarseness, and pulmonary signs including: asymmetry of respirations, rales, or wheezing.
Describe fluid management in the emergent phase, acute phase, and rehabilitation phase of the burned client.
State I (Emergent Phase): Replacement of fluids is titrated to urine output. Stage II (Acute Phase): Maintain patent infusion site in case supplemental IV fluids are needed; heparin lock is helpful; may use colloids. State III (Rehabilitation Phase): No extra fluids are needed, but high-protein drinks are recommended.
Burn depth is a measure of severity. Describe the characteristics of superficial partical-thickness, deep partial-thickness, and full-thickness burns.
Superficial partical-thickness: 1st degree=pink to red skin (i.e. sunburn), slight edema, and pain relieved by cooling. Deep partial-thickness: 2nd degree =destruction of epidermis and upper layers of dermis; white or red, very edematous, sensitive to touch and cold air, air does not pull out easily. Full-thickness: 3rd degree=total destruction of dermis and epidermis; reddened areas do not blanch with pressure, not painful, inelastic, waxy white skin to brown, leathery eschar.
What are the four categories of burns?
Thermal Radiation Electrical Chemical
Describe the method of extingishing each of the following burns: thermal, chemical, and electrical.
Thermal: remove clothing, immerse in tepid water. Chemical: flush with water or saline. Electrical: separate client from electrical source.
What are signs of infection in a burned patient?
elevated temperature, tachycardia, tachypnea, decreased blood pressure, hyperglycemia, decreased gastric function, altered mental status, and the conversion of burn wounds to include increased drainage and poor healing.