Burns- mine

Thermal Injury The instructor teaches nursing students about burns. Which explanation BEST describes the Rule of Nines as applied to burns? a. Each arm constitutes 9% of body surface area. b. Increase fluid resuscitation by 9% every hour. c. Calculate the amount of Silvadene needed by 9. d. Indicates the chances of recovery from a burn.

a. CORRECT - Rule of Nine is a quick method of calculating the approximate percentage of total body surface area that is burned; each arm constitues 9%, the anterior and posterior trunk are each 18%, each leg is 18%, the head is 9%, and the perineum is 1%; transfer of energy from a heat source to the body causes burns; there are three classifications of burn depth; with superficial partial-thickness burns (first-degree), the epidermis is affected (destroyed or injured) and there is painful, red, dry, or minimal or no edema; with deep partial-thickness burns (second-degree), the epidermis and part of the dermis is affected and there is painful, red, blistered edema that exudes fluid; with full thickness burns (third-degree), there is total destruction of the epidermis, entire dermis, and in some cases subcutaneous tissue,, muscle, or bone; there is painless, dry, and leathery edema that varies in color (white, red, brown, black, charred); third-degree burns includde symptoms of shock, and probable hematuria and hymolysis; burn injury nursing care: administer IV Lactated Ringer's and plasma; use an indwelling catheter to monitor hourly output (which should be at least 30 mL/hour); checkc for sings of fluid overload versus dehydration; monitor blood pressure, TPR, weight, and serum electrolytes; wound care at least once/day using sterile technique and while wearing cap, gown, mask, and gloves, tetanus prophylaxis; provide a high-caloric, high-carbohydrate, and high-protein diet; use TPN if necessary; administer analgesics 30 mintues before wound care to prevent contractions; administer pain medication intravenously due to impaired circulation and poor absorption; counsel the client regarding change in body image; encourage expression of feelings and demonstrate acceptance of client; evaluate client's readiness to see scarred areas (especially facial area); and prepare client for discharge. b. Fluid resuscitation is based on a variety of formulas; most fluid is replaced in first eight hours, then approximately the same amount over the next 16 hours, and less over the next 24 hours c. Rule of Nines is a quick method of calculating the approximate percentage of total body surface that is burned d. has nothing to do with calculating chances of recovery

Thermal Injury The toddler experiences burns on the back, right arm, and right leg. Using the Rule of Nines, what percentage does the nurse correctly estimate the extent of the burns to be? a. 18% b. 32% c. 45% d. 54%

a. too low b. too low c. CORRECT - right (R) arm = 9%, right (R) leg = 18%, back = 18%; total burned area equals = 45% d. too high

A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurses immediate, priority concern when planning this patients care? A)Fluid status B)Risk of infection C)Nutritional status D)Psychosocial coping

A)Fluid status

A patient in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the patients laboratory studies, the nurse will expect the results to indicate what? A)Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis B)Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis C)Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis D)Hypokalemia, hyponatremia, elevated hematocrit, and metabolic alkalosis

A)Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis

A nurse is caring for a patient in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values? A)Sodium deficit B)Decreased prothrombin time (PT) C)Potassium deficit D)Decreased hematocrit

A)Sodium deficit

The nurse is evaluating fluid resuscitation attempts in the burn client. Which finding indicates adequate fluid resuscitation? 1. Disorientation to time only 2. Heart rate of 95 beats/minute 3. +1 palpable peripheral pulses 4. Urine output of 30 mL over the past 2 hours

2. Heart rate of 95 beats/minute When fluid resuscitation is adequate, the heart rate should be less than 120 beats/minute, as indicated in option 2. In addition, adequacy of fluid volume resuscitation can be evaluated by determining if urine output is at least 30 mL/hour, peripheral pulses are +2 or better, and the client is oriented to client, place, and time.

The nurse is planning care for a client returning from the operating room after having an autograft applied to the right lower extremity. Which nursing intervention is focused on promoting graft "take"? 1. Monitor temperature every 4 hours. 2. Leave the dressing intact for 3 to 5 days. 3. Maintain the right lower extremity in a dependent position. 4. Apply an ice pack to the site to decrease edema formation.

2. Leave the dressing intact for 3 to 5 days. After surgery, graft sites are immobilized with bulky cotton pressure dressing for 3 to 5 days to allow vascularization, or "take," of the newly grafted skin. Dressings should not be disturbed. Elevation and complete rest of the grafted area is required to allow blood vessels to connect the graft with the wound bed. Any activity that might cause movement of the dressing against the body and separation of the graft from the wound is prohibited, such as application of an ice pack. Additionally, cold promotes vasoconstriction.

A patient has sustained a severe burn injury and is thought to have an impaired intestinal mucosal barrier. Since this patient is considered at an increased risk for infection, what intervention will best assist in avoiding increased intestinal permeability and prevent early endotoxin translocation? A)Early enteral feeding B)Administration of prophylactic antibiotics C)Bowel cleansing procedures D)Administration of stool softeners

A)Early enteral feeding

A patient is in the acute phase of a burn injury. One of the nursing diagnoses in the plan of care is Ineffective Coping Related to Trauma of Burn Injury. What interventions appropriately address this diagnosis? Select all that apply. A)Promote truthful communication. B)Avoid asking the patient to make decisions. C)Teach the patient coping strategies. D)Administer benzodiazepines as ordered. E)Provide positive reinforcement.

A)Promote truthful communication. C)Teach the patient coping strategies. E)Provide positive reinforcement.

A burn patient is transitioning from the acute phase of the injury to the rehabilitation phase. The patient tells the nurse, I cant wait to have surgery to reconstruct my face so I look normal again. What would be the nurses best response? A)Thats something that you and your doctor will likely talk about after your scars mature. B)That is something for you to talk to your doctor about because its not a nursing responsibility. C)I know this is really important to you, but you have to realize that no one can make you look like you used to. D)Unfortunately, its likely that you will have most of these scars for the rest of your life.

A)Thats something that you and your doctor will likely talk about after your scars mature.

An emergency department nurse learns from the paramedics that they are transporting a patient who has suffered injury from a scald from a hot kettle. What variables will the nurse consider when determining the depth of burn? A)The causative agent B)The patients preinjury health status C)The patients prognosis for recovery D)The circumstances of the accident

A)The causative agent

The nurse is caring for admitted to the ED with burns to the lower legs and hands. During the initial management, what is the priority nursing care? A. Assess and tx pain B. Evaluate airway and circulation C. IV caths for fluid D. rule of nines to estimate percent of body surface area burned

B

Twenty minutes later, assessment of the patient reveals loud wheezing on exhalation. What is the nurse's best action at this time? A. Check the pts. SaO2 with pulse oximetry B. Apply oxygen and call the Rapid Response Team C. Call a CODE and bring the crash cart to the room D. Call respiiatory therapy for bronchodilator treatment

B

A patient admitted with severe burns to his face and hands is showing signs of extreme agitation. The nurse should explore the mechanism of burn injury possibly related to a) excessive alcohol use b) methamphetamine use c) PTSD d) subacute delirium

B A vague or inconsistent injury history, burns to the face and hands, and signs of agitation or substance withdrawal should alert the nurse to a potential methamphetamine-related injury.

The nurse understands that negative-pressure wound therapy may be used in the treatment of partial-thickness burn wounds to do which of the following? a) Maintain a closed wound system to decrease the risk of infection b) Remove excessive wound fluid and promote moist wound healing c) Increase patient mobility w/ large burn wounds d) Quantify wound drainage amount for more accurate output assessment

B Negative-pressure wound therapy can be used to treat grafts or partial-thickness burns by decompressing edematous interstitial spaces that enhance local perfusion, optimizing wound healing. This therapy also provides a moist wound-healing environment.

Silver is used as an ingredient in many burn dressings because it a) stimulates tissue granulation b) is effective against a wide spectrum of wound pathogens c) provide topical pain relief d) stimulates wound healing

B Silver is an ingredient in many dressings because it helps prevent infection against a wide spectrum of common pathogens.

The nurse is caring for a patient who has circumferential full-thickness burns of his forearm. A priority in the plan of care is a) to keep the extremity in a dependent position b) active or passive ROM exercises every hour c) to prepare for a escharotomy as a prophylactic measure d) to splint the forearm

B Special attention is given to circumferential (completely surrounding a body part) full-thickness burns of the extremities. Pressure from bands of eschar or from edema that develops as resuscitation proceeds may impair blood flow to underlying and distal tissue. Therefore, extremities are elevated to reduce edema. Active or passive range-of-motion (ROM) exercises are performed every hour for 5 minutes to increase venous return and to minimize edema.

A(An) ____________________ often produces a superficial cutaneous injury but may cause cardiopulmonary arrest and transient but severe central nervous system deficits. a) chemical burn b) electrical burn c) heat burn d) infection

B Tissue damage results from the conversion of electrical energy into heat. Monitor the patient for cardiac dysrhythmias.

Which of the following factors increase the burn patient's risk for venous thromboembolism? (Select all that apply.) a) Burn injury less than 10% b) Bed rest c) Burns to lower extremities d) Electrical burn injury e) Delayed fluid resuscitation

B, C, E Venous thromboembolism (VTE) is a significant risk for patients who have thermal injury, venous stasis associated with immobility/bed rest, hypercoagulability seen with burn injuries greater than 10% TBSA, and hypovolemia associated with delayed fluid resuscitation. Burns to lower extremities will limit mobility and use of sequential compression devices, increasing the potential risk for VTE. Electrical burn injury may pose a risk for VTE; however, VTE is more closely associated with thermal injuries greater than 10% TBSA.

A patient experienced a 33% TBSA burn 72 hours ago. The nurse observes that the patients hourly urine output has been steadily increasing over the past 24 hours. How should the nurse best respond to this finding? A)Obtain an order to reduce the rate of the patients IV fluid infusion. B)Report the patients early signs of acute kidney injury (AKI). C)Recognize that the patient is experiencing an expected onset of diuresis. D)Administer sodium chloride as ordered to compensate for this fluid loss.

C)Recognize that the patient is experiencing an expected onset of diuresis.

A nurse is developing a care plan for a patient with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. What is the best rationale for this intervention? A)To prevent neuropathies B)To prevent wound breakdown C)To prevent contractures D)To prevent heterotopic ossification

C)To prevent contractures

A patient with a partial-thickness burn injury had Biobrane applied 2 weeks ago. The nurse notices that the Biobrane is separating from the burn wound. What is the nurses most appropriate intervention? A)Reinforce the Biobrane dressing with another piece of Biobrane. B)Remove the Biobrane dressing and apply a new dressing. C)Trim away the separated Biobrane. D)Notify the physician for further emergency-related orders.

C)Trim away the separated Biobrane.

Thermal Injury The client is admitted to the hospital after sustaining severe electrical burns. A tracheostomy is performed, and the client is unable to use either hand. It is MOST important for the nurse to take which action? a. Obtain a closed-circuit video monitor. b. Pad the side rails of the bed. c. Obtain a blow-touch call bell. d. Transfer the client with a Hoyer lift.

a. will allow the nurse to observe the client but does not offer the client the ability to contact the nurse b. will not assist with communication c. CORRECT - the client is unable to use either hand, so the most appropriate way for the client to summon the nurse is with a blow-touch call bell d. mechanically operated metal frame with a sling used for clients who cannot help themselves and/or are too heavy to lift safely; no indication for the need for a Hoyer lift

Which of the following nursing diagnoses for the patient with a burn Injury has the highest priority during the resuscitative phase? a. Impaired Gas Exchange related to inhalation injury. b. Ineffective airway clearance related to inhalation injury. c. Deficient fluid Volume related to third spacing of fluids. d. Pain related to burn injury.

b. Ineffective airway clearance related to inhalation injury.

The nurse is performing a primary burn assessment according to the ABCs (airway, breath, circulation) guidelines. Which of the following indicate signs and symptoms of inhalation injury? a.Facial swelling and bruising. b. Progressive stridor and hoarseness. c. Singed chest hairs. d. Increased body temperature.

b. Progressive stridor and hoarseness

Using the Parkland formula calculate the fluid volume for a 154 woman who has sustained a 36% mixed deep partial and full thickness burn. How much fluid would you administer during the first 8 hours of fluid resuscitation? a.10,080 milliliters. b. 20,160 milliliters. c. 5,040 milliliters. d. 2520 milliliters.

c. 5,040 milliliters

What immediate action should the occupational health nurse take once flames have been extinguished from a burned victim? 1. Remove jewelry. 2. Wrap in a clean blanket. 3. Cover burns with clean, dry cloth. 4. Briefly soak burned area in cool water.

4 pg 23 4. Correct: Although all options are correct, the priority is to stop the burning process. Just putting out the flames is not enough to stop the burning process. You need to apply cool water briefly (no more than 10 minutes) to soak the burn area. Any longer can cause extensive heat loss. 1. Incorrect: Removing jewelry is important but stop the burning process first. Swelling occurs with burns, so jewlrey must be removed or you will not get it off. This can result in constriction of the extemity. Additionally, metal burns. 2. Incorrect: Wrapping the client in a clean or preferably a sterile blanket will help to hold in body heat. Remember, they have lost skin, the number one way to hold in body heat. 3. Incorrect: Applying a clean, dry cloth to the burn area will help prevent infection, but the priority is to stop the burning process.

A burned client newly arrived from an accident scene is prescribed 4 mg of morphine sulfate intravenously. What is the most important reason the nurse administers the analgesic to this client by the intravenous (IV) route? A. The drug will be effective more quickly than if given IM or subcutaneously. B. It is less likely to interfere with the client's breathing and oxygenation. C. The danger of an overdose during fluid remobilization is reduced. D. The client has delayed gastric emptying.

ANS: C Rationale: Although providing some pain relief is a high priority and giving the drug by the IV route instead of the IM, subcutaneous, or oral routes does increase the rate of effect, the most important reason is to prevent an overdose from the accumulation of drug in the interstitial space during the fluid shift of the emergent phase. When edema is present, cumulative doses are rapidly absorbed while the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics.

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? 1. Nerve damage 2. Hypertrophy of collagen fibers 3. Compromised circulation at the burn site 4. Increase in subcutaneous tissue at the burn site

2. Hypertrophy of collagen fibers Keloids are visible as excessive scar formation and result from hypertrophy of collagen fibers. Nerves conduct sensory and motor impulses from the skin. The vasculature provides blood vessels with nourishment and assists in thermoregulation. Subcutaneous tissue provides for heat insulation, mechanical shock absorption, and caloric reserve.

Person is burned on the back and posterior arm. A client arrives at the emergency department after sustaining full thickness burns. What does the nurse estimate the total body surface area (TBSA) burned to be when using the rule of nines?

22.5 pg 22 posterior trunk = 18 posterior arm =4.5

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? 1. 1200 mL of 5% dextrose in water solution 2. 2400 mL of 0.45% normal saline solution 3. 4800 mL of 0.9% normal saline solution 4. 9600 mL of lactated Ringer's solution

4. 9600 mL of lactated Ringer's solution The Parkland (Baxter) formula is 4 mL of lactated Ringer's solution × kg body weight × percent burn. The calculation is performed as follows: 4 mL × 60 kg × 40 = 9600 mL.

Which action by the nurse changing the dressings on the client who has burns on the right arm, the left arm, and the upper chest is most effective at preventing autocontamination? A Changing gloves after cleaning and dressing one wound area before cleaning and dressing the next wound area. B Using sterile gloves to remove the old dressings and changing to fresh sterile gloves before applying the new dressings. C Ensuring that the blood pressure cuff used on another client is thoroughly cleaned before using it on this client. D Warning the client's family not to bring fresh fruits and vegetables or house plants into the client's environment.

A

A 63-year-old patient is admitted with new-onset fever; flulike symptoms; blisters over the arms, chest, and neck; and red, painful oral mucous membranes. The patient should be further evaluated for which possible non-burn-injured skin disorder? a) Toxic epidermal necrolysis b) Staphylococcal scalded skin syndrome c) Necrotizing soft tissue infection d) Graft vs. host disease

A Patients with toxic epidermal necrolysis, Stevens-Johnson Syndrome (SJS), and erythema multiforme present with acute-onset fever and flulike symptoms, with erythema and blisters developing within 24 to 96 hours; skin and mucous membranes slough, resulting in a significant and painful partial-thickness injury.

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? A) Return of distal pulses B) Brisk bleeding from the site C) Decreasing edema formation D) Formation of granulation tissue

A) Return of distal pulses

A nurse on a burn unit is caring for a patient in the acute phase of burn care. While performing an assessment during this phase of burn care, the nurse recognizes that airway obstruction related to upper airway edema may occur up to how long after the burn injury? A)2 days B)3 days C)5 days D)1 week

A)2 days

Which assessment does the nurse perform first on the client just admitted after an electrical injury with contact sites on the left hand and left foot? A. Core body temperature B. Electrocardiography C. Depth of burn injury D. Urine output

B

The nurse is caring for a burn-injured patient who weighs 154 pounds, and the burn injury covers 50% of his body surface area. The nurse calculates the fluid needs for the first 24 hours after a burn injury using a standard fluid resuscitation formula of 4 mL/kg/% burn of intravenous (IV) fluid for the first 24 hours. The nurse plans to administer what amount of fluid in the first 24 hours? a) 2800 mL b) 7000 mL c) 14 L d) 28 L

C 154 pounds/2.2 = 70 kg 4 × 70 kg × 50 = 14,000 mL, or 14 liters.

An adult client was burned in an explosion. The burn initially affected the client's entire face. and the upper of 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 bet the extent of the burn injury? A) 18% B) 24% C) 36% D) 48%

C) 36%

The burn nurse is aware that wound care during the acute phase involves consideration of which of the following? a. First and superficial second-degree burns can usually be managed with clean technique. b. Deep second-degree burns with or without impaired circulation heal without surgical intervention. c. Full thickness burns require surgical intervention to heal. d. The presence of infection is a contraindication to surgical wound management.

c. Full thickness burns require surgical intervention to heal.

The burn client asks the nurse not to remove the loosened bits of skin and tissue during the dressing change, saying "The more skin you take off, the longer it will take me to heal." What is the nurse's best response? A. "Do you want some pain medication before I begin?" B. "The only things I am removing are blocks of bacteria growth, not skin." C. "Don't worry, I have worked the burn unit for years and know what I am doing." D. "This tissue is no longer living and as long as it is present, real healing cannot start."

ANS: D Rationale: Clients often do not understand that removal of dead tissue must occur before healing can start; they view the débridement as making the situation worse. Helping them understand the rationale for the procedure may help them accept the process and alleviate their concern that débridement is inappropriate or harmful

The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client? A) Out-of-bed activities B) Bathroom privileges C) Immobilization of the affected leg D) Placing the left leg in a dependent position

C) Immobilization of the affected leg

What sign/symptom would indicate to the nurse that a client has had an inhalation injury? 1. stridor 2. Swallowing difficulty 3. Singed nasal hair 4. Blisters to upper arms 5. Wheezing

1, 2, 3, & 5 pg 25 1., 2., 3., & 5. Correct: Substernal/intercostal retraction and stridor are bad signs. Remember you will see difficulty swallowing, singed nasal and facial hair, and wheezing. 4. Incorrect: Blisters found on the oral/pharyngeal mucosa is more likely to indicate a smoke or inhalation injury.

A client is diagnosed with a full-thickness burn. What should the nurse anticipate will be used for final coverage of the client's burn wound? 1. Biobrane 2. Autograft 3. Homograft 4. Xenograft

2. Autograft A full-thickness burn will require terminal coverage with an autograft-the client's own skin. Biobrane is porcine collagen bonded to a silicone membrane, which is temporary and lasts anywhere from 10 to 21 days. Homografts (cadaveric skin) and xenografts (pigskin) provide temporary coverage of the wound by acting as a dressing for up to 3 weeks before rejecting.

A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand? 1. A pink, edematous hand 2. Fiery red skin with edema in the nail beds 3. Black fingertips surrounded by an erythematous rash 4. A white color to the skin, which is insensitive to touch

4 Assessment findings in frostbite include a white or blue color; the skin will be hard, cold, and insensitive to touch. As thawing occurs, flushing of the skin, the development of blisters or blebs, or tissue edema appears. Options 1, 2, and 3 are incorrect.

The nurse is caring for patient who has been struck by lightning. Because of the nature of the injury, the nurse assesses the patient for which of the following? a) CNS deficits b) Contractures c) Infection d) Stress ulcers

A Lightning injury frequently causes cardiopulmonary arrest. However, of those patients who survive, 70% will have transient central nervous system deficits.

Which symptom does the nurse that may indicate a pulmonary injury from the inhalation? SATA a. Brassy cough b. Drooling c. Clear speech d. Audible wheezes e. clear breath sounds

ABD

The CVP reading of a client with partial thickness burns is 6 mm H2O. The nurse recognizes that the client: A. Needs additional fluids B. Has a normal CVP reading C. May show signs of congestive failure D. Would benefit from a diuretic

B. Has a normal CVP reading

The current phase of a patients treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the patient is in what phase of burn care? A)Emergent B)Immediate resuscitative C)Acute D)Rehabilitation

C)Acute

For which type of burn injury is it most important for the nurse to assess the client for a respiratory injury? A Hot liquid scald burn B Liquid chemical burn C Electrical burn D Dry heat burn

D

A patient arrives in the emergency department after being burned in a house fire. The patients burns cover the face and the left forearm. What extent of burns does the patient most likely have? A)13% B)25% C)9% D)18%

D)18%

On the third post-burn day, the nurse finds that the client's hourly urine output is 26 ml. The nurse should continue to assess the client and notify the doctor for an order to: A. Decrease the rate of the intravenous infusion. B. Change the type of intravenous fluid being administered. C. Change the urinary catheter. D. Increase the rate of the intravenous infusion.

D. Increase the rate of the intravenous infusion

A Jewish client requires grafting to promote burn healing. Which graft is most likely to be unacceptable to the client? A. Isograft B. Autograft C. Homograft D. Xenograft

D. Xenograft

A nurse has developed a nursing diagnosis of Ineffective Airway Clearance for a client who sustained an inhalation burn injury. Which nursing intervention would the nurse include in the plan of care for the client? a) monitor oxygen saturation levels every shift b) encourage coughing and deep breathing every 4 hours c) elevate the head of the bed continually d) assess respiratory rate and breath sounds every 2 hours

c) elevate the head of the bed continually

Thermal Injury The nurse determines the client has a deep partial thickness burn injury of the back. Which is the BEST initial nursing action? a. Break the blisters with scalpel using technique. b. Gently clean the area and then leave it alone. c. Apply a think layer of petroleum jelly to the area. d. Warp snugly with sterile gauze.

a. blister provides a protective covering; leave intact b. CORRECT - for a deep partial thickness burn, gently clean way debris and dirt; blisters form a protective cover, so leave intact, without applying a sterile gauze c. leave uncovered d. leave uncovered

A client sustains a high-voltage electrical injury while at work. Which interventions should the occupational health nurse initiate? 1. Assess entry and exit wound. 2. Monitor vital signs. 3. Place on a spine board. 4. Connect to cardiac monitor. 5. Perform the rule of nines. 6. Apply cervical collar to neck.

1, 2, 3, 4, & 6 pg 34 1., 2., 3., 4., & 6. Correct: You need to understand that high-voltage current of electricity damages the vascular system and the nerves nearby. This alteration in the vascular system can damage vital organs, so we worry about organ failure. Electrical burns have two wounds: an entrance burn wound that is generally small and an exit burn wound that is much larger. The electricity goes throughout the body causing damage, and then exits the body. So look for 2 burn wounds. Remember, vessels, nerves, and organs can be damaged. The nurse needs to monitor vital signs frequently, especially those assessing the respiratory and cardiac systems, since we worry about organ damage. Electricity can damage the heart muscle, so the client is at risk for dysrhythmias within 24 hours following an electrical burn. Put the client on continuous cardiac monitoring during this time. Why place the client on a spine board and put a c-collar on? Contact with electricity can cause muscle contractions strong enough to fracture bones, or vertebrae. The force of the electricity can actually throw the victim forcefully. 5. Incorrect: This statement is false. The rule of nines is not used for electrical burns, but for thermal burns. Most of the damage from electrical burns is internal and cannot be determined by using the rule of nines.

A client with deep partial thickness burns to arms and legs is admitted to the burn unit. The nurse knows elevated results are most likely to be noted initially in what laboratory tests? 1. Hematocrit 2. Albumin 3. Potassium 4. Creatinine 5. Magnesium

1, 3, & 4 pgs 4-5 & 26-27 1, 3, & 4. CORRECT. The physiology of the body changes significantly following a major burn. Hematocrit increases as the fluid from the vascular spaces leaks into the interstitial tissues. Because of lysis of cells, potassium is released into the circulation, leading to hyperkalemia. The kidneys are impacted by the decreased cardiac output as well as the myoglobin released by the lysed cells. This causes creatinine to become elevated. 2. INCORRECT. Albumin, a body protein, is lost through the damaged skin areas and secondary to increased capillary permeability. 5. INCORRECT. Magnesium is a major electrolyte necessary for both muscle and nerve function. Since the body does not produce magnesium naturally, humans need a well-balanced diet which includes a variety of vegetables and seeds. Levels of magnesium are not affected during the initial period after a burn.

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 health care provider's prescriptions and should plan to question which prescription? 1. Gastric lavage 2. Intravenous (IV) fluid therapy 3. Nothing by mouth (NPO) status 4. Preparation for laboratory studies

1. Gastric lavage The client who has sustained chemical burns to the esophagus is placed on NPO status, is given IV fluids for replacement and treatment of possible shock, and is prepared for esophagoscopy and barium swallow to determine the extent of damage. Laboratory studies also may be prescribed. A nasogastric tube may be inserted, but gastric lavage and emesis are avoided to prevent further erosion of the mucosa by the irritating substances that these treatments involve.

A client is on nothing by mouth (NPO) status and has a nasogastric (NG) tube in place after suffering bilateral burns to the legs. The nurse determines that the client's gastrointestinal (GI) status is least satisfactory if which finding is noted on assessment? 1. Gastric pH of 3 2. Absence of abdominal discomfort 3. GI drainage that is guaiac negative 4. Presence of hypoactive bowel sounds

1. Gastric pH of 3 The gastric pH should be maintained at 7 or greater with the use of prescribed antacids and histamine 2 (H2) receptor-blocking agents. Lowered pH (to the acidic range) in the absence of food or tube feedings can lead to erosion of the gastric lining and ulcer development. Absence of discomfort and bleeding (guaiac-negative drainage) are normal findings. The client's bowel sounds may be expected to be hypoactive in the absence of oral or NG tube intake.

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? 1. Return of distal pulses 2. Brisk bleeding from the site 3. Decreasing edema formation 4. Formation of granulation tissue

1. Return of distal pulses Escharotomies are performed to relieve the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential third-degree burn. The escharotomy releases the tourniquet-like compression around the arm. Escharotomies are performed through avascular eschar to subcutaneous fat. Although bleeding may occur from the site, it is considered a complication rather than an anticipated therapeutic outcome. Usually, direct pressure with a bulky dressing and elevation control the bleeding, but occasionally an artery is damaged and may require ligation. Escharotomy does not affect the formation of edema. Formation of granulation tissue is not the intent of an escharotomy.

What information on burn prevention strategies should the nurse include when providing an education program at a community center? 1. Have chimney professionally inspected every 5 years. 2. Clean the lint trap on the clothes dryer after each use. 3. Keep anything that can burn at least 1 foot (0.30 meters) away from space heaters. 4. Do not hold a child while holding a hot drink. 5. Home hot water heater should be set at a maximum of 120°F (48.8°C).

2, 4, & 5 pg 20 2., 4., & 5. Correct: Lint that accumulates in the lint trap of a dryer can cause a fire, so the lint trap should be cleaned after each use. A hot beverage can easily spill on a child by accident when trying to handle both the beverage and child at the same time. Home hot water heater should be set at a maximum of 120°F (48.8°C), especially when small children, the elderly, or diabetics are in the home. 1. Incorrect: A chimney should be professionally inspected every year prior to use. It should also be cleaned if necessary. 3. Incorrect: Space heaters need space at least three feet (0.91 meters) away from anything that can burn.

A client is admitted to the hospital emergency department after receiving a burn injury in a house fire. The skin on the client's trunk is tan, dry, and hard. It is edematous but not very painful. The nurse determines that this client's burn should be classified as which type? 1. Superficial 2. Full-thickness 3. Deep partial-thickness 4. Partial-thickness superficial

2. Full-thickness Full-thickness burns involve the epidermis, the full dermis, and some of the subcutaneous fat layer. The burn appears to be a tan or fawn color, with skin that is hard, dry, and inelastic. Edema is severe, and the accumulated fluid compresses tissue underneath because of eschar formation. Some nerve endings have been damaged, and the area may be insensitive to touch, with little or no pain.

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? 1. White color 2. Pink or red color 3. Weeping blisters 4. Insensitivity to pain and cold

2. Pink or red color Superficial burns are pink or red without any blistering. The skin blanches to touch, may be edematous and painful, and heals on its own, usually within 1 week. A white color characterizes deep partial-thickness burns. Weeping blisters characterize partial-thickness superficial burns. Deep full-thickness burns are associated with insensitivity to pain and cold.

The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries 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? 1. Vital signs 2. Urine output 3. Mental status 4. Peripheral pulses

2. Urine output Successful or adequate fluid resuscitation in the client is signaled by stable vital signs, adequate urine output, palpable peripheral pulses, and clear sensorium. However, the most reliable indicator for determining adequacy of fluid resuscitation, especially in a client with burns, is the urine output. For an adult, the hourly urine volume should be 30 to 50 mL.

A client is admitted to the emergency department with a full-thickness burn to the right arm. Upon assessment, the arm is edematous, fingers are mottled, and radial pulse is now absent. The client states that the pain is 8 on a scale of 1 to 10. The nurse should: 1. Administer morphine sulfate IV push for the severe pain. 2. Call the physician to report the loss of the radial pulse. 3. Continue to assess the arm every hour for any additional changes. 4. Instruct the client to exercise his fingers and wrist

2. Call the physician to report the loss of the radial pulse. Circulation can be impaired by circumferential burns and edema, causing compartment syndrome. Early recognition and treatment of impairedblood supply is key. The physician should be informed since an escharotomy (incision through full-thickness eschar) is frequently performed to restorecirculation.

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 to be? Fill in the blank.......%

22.5% According to the rule of nines, 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%.

While performing wound care to a donor skin graft site, the nurse notes some scabbing around the edges and a dark collection of blood. What is the nurse's next action? 1. eave the scabbing area alone and apply extra ointment. 2. Notify the primary healthcare provider. 3. Gently remove the debris and re-dress the wound. 4. Apply skin softening lotion for 3 hours and then re-dress.

3 pg 24 3. Correct: What likes to live in the scabs and dried blood? Bacteria. That is why it is important to remove the debris to prevent infection. 1. Incorrect: This is not appropriate because bacteria is in the scabbing area and ointment would trap it, enhance reproduction of the germs, and increase infection. 2. Incorrect: There is no need to notify primary healthcare provider at this time. This is not the best option for the nurse to fix the problem. 4. Incorrect: We don't put lotion in the wound because this would cause infection of the wound.

An elderly client with partial and full-thickness burns has begun receiving fluids at 600 ml/hour, as determined by the Parkland (Consensus) Formula. Based on the assessment data for the first four hours, what should the nurse report to the primary healthcare provider? Pts vital show that overtime there was a increase in temp to a normal body temp, decrease in pulse, increase in BP, decrease in RR, and increase in CVP. 1. The cardiovascular system is becoming seriously overloaded 2. The speed of the IV should be reduced since CVP is now normal 3. The changes in vital signs indicate an expected response to fluids 4. The client is deteriorating because of age and extent of the burns

3 pgs 4-5 & 22-26 3. CORRECT. The purpose of infusing large amounts of fluid into burn victims during the first 24 hours is to help maintain perfusion until the body's physiology returns to normal functioning. The serial vital signs indicate the cardiovascular system is stabilizing, as evidenced by pulse decreasing to the normal range while blood pressure increases. Though respirations are still slightly elevated, the client would likely be experiencing pain. Most importantly, the CVP (central venous pressure) has increased to the normal range, indicating the fluid replacement is adequate at this time. 1. INCORRECT. There is no evidence indicating possible cardiac overload. The client's vital signs are stabilizing and the central venous pressure (CVP) has returned to normal limits. 2. INCORRECT. When fluid replacement is calculated for burn clients, the amount is based on client weight in kilograms and total surface area burned. Those parameters do not change during the initial treatment. Therefore the amount of fluid needed during the first 24 hours remains unchanged until after that time frame, even if vital signs improve. 4. INCORRECT. The hourly data does not reflect deterioration. Vital signs are slowly returning to within normal range and there is no mention in the scenario about the extent of burns.

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? 1. "The medication is an antibacterial." 2. "The medication will help heal the burn." 3. "The medication is likely to cause stinging every time it is applied." 4. "The medication should be applied directly to the wound."

3. "The medication is likely to cause stinging every time it is applied." Silver sulfadiazine is an antibacterial that has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. It is applied directly to the wound to assist in healing. It does not cause stinging when applied.

The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client? 1. Out-of-bed activities 2. Bathroom privileges 3. Immobilization of the affected leg 4. Placing the affected leg in a dependent position

3. Immobilization of the affected leg Autografts placed over joints or on the lower extremities after surgery often are elevated and immobilized for 3 to 7 days. This period of immobilization allows the autograft time to adhere to the wound bed. Getting out of bed, going to the bathroom, and placing the grafted leg dependent would put stress on the grafted wound.

A client sustained a burn from cutaneous exposure to lye. At the site of injury, copious irrigation to the site was performed for 1 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? 1. Eschar 2. Intact blisters 3. Liquefaction necrosis 4. Cherry-red, firm tissue

3. Liquefaction necrosis Alkalis, such as lye, cause a liquefaction necrosis, and exposure to fat results in formation of a soapy coagulum. Thick, leathery eschar forms with exposure to acids or heat. Intact blisters indicate a partial-thickness thermal injury. Cherry-red, firm tissue can occur as a result of thermal injury.

A burn client has been having 1% silver sulfadiazine applied to burns twice a day for the past 3 days. Which laboratory abnormality indicates that the client is experiencing a side or adverse effect of this medication? 1. Serum sodium of 120 mEq/L (120 mmol/L) 2. Serum potassium of 3.0 mEq/L (3.0 mmol/L) 3. White blood cell count of 3000 mm3 (3 × 109/L) 4. pH 7.30, PaCO2 of 32 mm Hg (32 mmHg), HCO3- of 19 mEq/L (19 mmol/L)

3. White blood cell count of 3000 mm3 (3 × 109/L) Transient leukopenia typically occurs after 2 to 3 days of treatment. Knowing this and knowing normal white blood cell values will direct you to option 3. Although options 1, 2, and 4 are abnormal findings, they are not associated with this medication.

An adult client was burned in an explosion. The burn initially affected the client's 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 client's 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? 1. 18% 2. 24% 3. 36% 4. 48%

3. 36% According to the rule of nines, with the initial burn, the anterior half of the head equals 4.5%, the upper half of the anterior torso equals 9%, and the lower half of both arms equals 9%. The subsequent burn included the posterior half of the head, equaling 4.5%, and the upper half of posterior torso, equaling 9%. This totals 36%.

A client weighing 166 pounds (75 kg) is brought to the emergency room with burns to the front and back of both legs and feet. Using the American Burn Association formula to calculate the amount of fluid needed for the first 24 hours, the nurse should set the infusion rate at what for the first eight hours? (Round to nearest whole number).

338 pgs 22 & 26 The American Burn Association formula is 2 - 4mL x weight in kilograms x total surface area burned. Based on the Rule of Nines for adults, a leg is 9% on the front and 9% on the back, which includes the feet. So both legs equal 36% (9% times 4) total surface area burned. The standard multiplier for thermal burns is considered to be 2 mL. Therefore: 2mL x 75 kg x 36 = 5,400 mL for 24 hours. Half that amount, or 2700 mL, should be infused in the first eight hours. Dividing that amount by 8 hours, the infusion rate would be 338 mL per hour.

An elderly client arrives at the emergency room reporting a severe headache and blurred vision. The client indicates having awakened this morning with flu-like symptoms including nausea, vomiting and dizziness. The nurse notes the client appears very weak with shortness of breath and dark cherry red lips. Based on assessment findings, what life-threatening problem does the nurse expect? 1. Guillian Barre 2. Severe dehydration 3. Advanced influenza 4. Carbon monoxide poisoning

4 pg 24 4. CORRECT. Carbon monoxide is a colorless, odorless, tasteless gas which permeates the blood stream, displacing the oxygen in hemoglobin. Symptoms are often confused with other illnesses, such as the flu. Assuming exposure is not fatal, the client may also experience extreme weakness, dizziness and blurred vision with confusion. Additionally, the carbon monoxide will cause lips and skin to become red in color. Without treatment, the client will die. 1. INCORRECT. Guillian-Barre is a muscle disorder occurring when the immune system attacks peripheral nerves, destroying the surrounding myelin sheath. The damage can develop over hours or days, but will take months to resolve. The client experiences severe weakness, drooping of the eye muscles and pain or tingling in hands and feet. The client also develops paresthesia and paralysis, which was not reported as symptoms in the scenario. Of major concern would be paralysis of the respiratory muscles. 2. INCORRECT. Although the client reported nausea and vomiting, there are no assessment findings in the scenario to corroborate severe dehydration. 3. INCORRECT. The client has reported flu-like symptoms, such as dizziness, nausea and vomiting along with headache. However, additional reported symptoms like blurred vision suggest a different problem.

The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury? 1. Decreased heart rate 2. Increased urinary output 3. Increased blood pressure 4. Elevated hematocrit levels

4. Elevated hematocrit levels The resuscitation/emergent phase begins at the time of injury and ends with the restoration of capillary permeability, usually at 48 to 72 hours following the injury. During the resuscitation/emergent phase, the hematocrit level increases to above normal because of hemoconcentration from the large fluid shifts. Hematocrit levels of 50% to 55% (0.50 to 0.55) are expected during the first 24 hours after injury, with return to normal by 36 hours after injury. Initially, blood is shunted away from the kidneys and renal perfusion and glomerular filtration are decreased, resulting in low urine output. The burn client is prone to hypovolemia and the body attempts to compensate by increased pulse rate and lowered blood pressure. Pulse rates are typically higher than normal, and the blood pressure is decreased as a result of the large fluid shifts.

The nurse is caring for a client with full-thickness circumferential burns of the entire trunk of the body. Which finding suggests that an escharotomy may be necessary? 1. Pallor of all extremities 2. Pulse oximetry reading of 93% 3. Peripheral pulses are diminished 4. High pressure alarm keeps sounding on the ventilator

4. High pressure alarm keeps sounding on the ventilator A client with a circumferential burn of the entire trunk likely will be on a ventilator because of the potential for breathing to be affected by this injury. The high pressure alarm will sound on the ventilator when there is any kind of obstruction. If the chest cannot expand due to restriction by eschar and increasing edema, this results in obstruction.

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? 1. Allow the client to have full liquids. 2. Give the client small glasses of clear liquids. 3. Order the client a full meal tray with extra liquids. 4. Keep the client on NPO (nothing by mouth) status.

4. Keep the client on NPO (nothing by mouth) status. The client should be maintained on NPO status because burn injuries frequently result in paralytic ileus. The client also should be told that fluids could cause vomiting because of the effect of the burn injury on gastrointestinal tract functioning. Mouth care should be given as appropriate to alleviate the sensation of thirst.

The nurse prepares to treat a client with frostbite of the toes. Which action should the nurse anticipate will be prescribed for this condition? 1. Rapid and continuous rewarming of the toes after flushing returns 2. Rapid and continuous rewarming of the toes in cold water for 45 minutes 3. Rapid and continuous rewarming of the toes in hot water for 15 to 20 minutes 4. Rapid and continuous rewarming of the toes in a warm water bath until flushing of the skin occurs

4. Rapid and continuous rewarming of the toes in a warm water bath until flushing of the skin occurs Acute frostbite is treated ideally with rapid and continuous rewarming of the tissue in a warm water bath for 15 to 20 minutes or until flushing of the skin occurs. Slow thawing or interrupted periods of warmth are avoided because they can contribute to increased cellular damage. Cold or hot water is not used. Thawing can cause considerable pain, and the nurse administers analgesics as prescribed.

The nurse is caring for a client who was admitted to the burn unit after sustaining a burn injury covering 30% of the body. What is the most appropriate time frame for the emergent phase? 1. The entire period of time during which rehabilitation occurs 2. The period from the time the client is stable to the time when all burns are covered with skin 3. The period from the time the burn was incurred to the time when the client is admitted to the hospital 4. The period from the time the burn was incurred to the time when the client is considered physiologically stable

4. The period from the time the burn was incurred to the time when the client is considered physiologically stable The emergent phase of burn care generally extends from the time the burn injury is incurred until the time when the client is considered physiologically stable. The acute phase lasts until all full-thickness burns are covered with skin. The rehabilitation period lasts approximately 5 years for an adult and includes reintegration into society.

Silver sulfadiazine is prescribed for a client with a burn injury. Which laboratory finding requires the need for follow-up by the nurse? 1. Glucose level of 99 mg/dL (5.65 mmol/L) 2. Magnesium level of 1.5 mEq/L (0.75 mmol/L) 3. Platelet level of 300,000 mm3 (300 × 109/L) 4. White blood cell count of 3000 mm3 (3.0 × 109/L)

4. White blood cell count of 3000 mm3 (3.0 × 109/L) Silver sulfadiazine is used for the treatment of burn injuries. Adverse effects of this medication include rash and itching, blue-green or gray skin discoloration, leukopenia, and interstitial nephritis. The nurse should monitor a complete blood count, particularly the white blood cells, frequently for the client taking this medication. If leukopenia develops, the health care provider is notified and the medication is usually discontinued. The white blood cell count noted in option 4 is indicative of leukopenia. The other laboratory values are not specific to this medication, and are also within normal limits.

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? Fill in the blank.........%

54% According to the rule of nines, the right arm is equal to 9% and the left arm is equal to 9%. The right leg is equal to 18% and the left leg is equal to 18%. The anterior thorax is equal to 18% and the posterior thorax is equal to 18%. The head is equal to 9% and the perineum is equal to 1%. If the anterior thorax, the right leg, and the right and left arms were burned, according to the rule of nines, the total area involved would be 54%.

The nurse is caring for a patient with a chemical burn injury. The priority nursing intervention is to a) remove the patient's clothes and flush the area with water b) apply saline compresses c) contact a poison control center for directions on neutralizing agents d) remove all jewelry

A As long as the chemical remains in contact with the skin, burn damage will result. Priority interventions are to remove the patient's clothes, brush loose chemical away from the skin and apply water for at least 30 minutes. Water needs to washed away from the body, not applied as compresses.

A nurse has reported for a shift at a busy burns and plastics unit in a large university hospital. Which patient is most likely to have life-threatening complications? A)A 4-year-old scald victim burned over 24% of the body B)A 27-year-old male burned over 36% of his body in a car accident C)A 39-year-old female patient burned over 18% of her body D)A 60-year-old male burned over 16% of his body in a brush fire

A)A 4-year-old scald victim burned over 24% of the body

A patient who is in the acute phase of recovery from a burn injury has yet to experience adequate pain control. What pain management strategy is most likely to meet this patients needs? A)A patient-controlled analgesia (PCA) system B)Oral opioids supplemented by NSAIDs C)Distraction and relaxation techniques supplemented by NSAIDs D)A combination of benzodiazepines and topical anesthetics

A)A patient-controlled analgesia (PCA) system

A public health nurse has reviewed local data about the incidence and prevalence of burn injuries in the community. These data are likely to support what health promotion effort? A)Education about home safety B)Education about safe storage of chemicals C)Education about workplace health threats D)Education about safe driving

A)Education about home safety

A patient is admitted to the burn unit after being transported from a facility 1000 miles away. The patient has burns to the groin area and circumferential burns to both upper thighs. When assessing the patients legs distal to the wound site, the nurse should be cognizant of the risk of what complication? A)Ischemia B)Referred pain C)Cellulitis D)Venous thromboembolism (VTE)

A)Ischemia

Which of the following statements about the pain management of a burn victim are true? (Select all that apply.) a) Additional pain medication may be needed because of rapid body metabolism. b) Pain medication should be given before procedures such as debridement, dressing changes, and physical therapy. c) Patients with a history of drug and alcohol abuse will require higher doses of pain medication. d) The IM route is preferred for pain medication administration. e) Patients w/ a history of drug and alcohol abuse should not need as much pain medication as other patients.

A, B, C The rapid metabolism associated with burn injury may require additional pain medication. Many of the procedures associated with burn wounds are painful, such as dressing changes. Adequate pain medication should be given before the procedures. Edema in burned patients alters the absorption of medications that are injected intramuscularly; therefore, drugs must be administered by the IV route. A history of drug and/or alcohol abuse does not change the pain experience for this patient; they will need as much pain medication as other burn patients and in fact may need more due to increased tolerance to the effects of the medication.

An autograft is used to optimally treat a partial- or full-thickness wound that (Select all that apply.) a) involves a joint b) involved the face, hands, or feet c) is infected d) requires more than 2 weeks for healing e) involved very large surface areas

A, B, D Autograft skin will allow for faster healing with less scar formation and a shorter hospitalization. Grafting is not done while a burn is infected. There may not be enough healthy skin to graft large areas.

The nurse is caring for a patient with burns to the hands, feet, and major joints. The nurse plans care to include which of the following? (Select all that apply.) a) Applying splints that maintain the extremity in an extended position b) Implementing passive or active ROM exercises c) Keeping the limbs as immobile as possible d) Wrapping fingers and toes individually with bandages e) Administering muscle relaxants around the clock

A, B, D It is important to avoid immobility in patients with burns of the hands, feet, or major joints. Measures must be taken to maintain the function of the hands, feet, and major joints. Nursing interventions to maintain range of motion, applying splints to keep the extremities in a position of function, and individually wrapping fingers and toes are necessary to maintain function of the hands, feet, and joints. Effective pain management is necessary to encourage mobility.

Which complications may manifest after an electrical injury? (Select all that apply.) a) Long bone fractures b) Cardiac dysrhthmias c) Hypertension d) Compartment syndrome of extremities e) Dark brown urine f) Peptic ulcer disease g) Acute cataract formation h) Seizures

A, B, D, E, G, H Electrical injuries vary in severity of injury by the intensity of energy exposed to the body. Manifestations and complications may include cardiac dysrhythmias or cardiopulmonary arrest, hypoxia, deep tissue necrosis, rhabdomyolysis and acute kidney injury, compartment syndrome, long bone fractures, acute cataract formation, and neurological deficits (including seizures). Hypertension and peptic ulcer disease are not direct consequences of electrical burn injuries.

Which of the following infection control strategies should the nurse implement to decrease the risk of infection in the burn-injured patient? (Select all that apply.) a) Apply topical antibacterial wound ointments/dressings b) Change indwelling urinary catheter every 7 days c) Daily assess the need for central IV catheters d) Restrict family visitation e) Maintain strict aseptic technique during burn wound management

A, C, E Nurses can help reduce the risk of infection by using topical antibacterial wound ointments and dressings as prescribed, daily questioning the need for invasive devices such as central IV access and indwelling urinary catheters, and maintaining aseptic technique during all care provided to the patient. Changing the indwelling urinary catheter will not reduce the risk of infection; wound care is achieved by aseptic technique; and restricting family is not an intervention related to infection prevention.

The physician has prescribed Protonix (pantoprazole) for a client with burns. The nurse recognizes that the medication will help prevent the development of: A. Curling's ulcer B. Myoglobinuria C. Hyperkalemia D. Paralytic ileus

A. Curling's ulcer

The nurse is caring for a client with an electrical burn. Which structures have the greatest risk for soft tissue injury? A. Fat, tendons, and bones B. Skin and hair C. Nerves, muscle, and blood vessels D. Skin, fat, and muscle

A. Fat, tendons, and bones

Which laboratory result would be expected during the emergent phase of a burn injury? A. Glucose 100 mg/dL B. Potassium 3.5 mEq/L C. Sodium 142 mEq/L D. Albumin 4.2 gm/dL

A. Glucose 100 mg/dL

Which statement made by the client who experienced burns to the head and neck indicates positive adjustment to the injury? A. "I am planning on cutting the grass in the mornings when the sun isn't as strong." 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."

ANS: A Rationale: Reintegrating into the family situation and assuming the roles and responsibilities performed before the injury are positive signs of beginning successful adjustment. Not looking at the wounds and not participating in family life are indicators of poor adjustment. Although it is good that the client is venturing outside of the home, the fact that he wants to remain unseen is a less positive indicator of adjustment.

The client who tripped while carrying an open kettle of hot water received scald burns to the entire chest, the entire anterior section of the right arm, the right half of the abdomen, and the anterior portion of the right 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. 22% to 23% B. 30% to 31% C. 39% to 40% D. 48% to 49%

ANS: A Rationale: The anterior thorax, which includes the chest and abdomen, is 18% of the total body surface area. Therefore the entire chest and half of the abdomen would be 13.5%. The anterior right area adds another 4.5%, bringing the total to 18%. The anterior section of the right thigh adds another 4.5%, bringing the total body surface area involved in this injury to approximately 22% to 23%.

The client with 45% burns has a hematocrit of 52% 10 hours after the burn injury and 6 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 physician or the Rapid Response Team. C. Document the report as the only action. D. Increase the IV infusion rate.

ANS: A Rationale: The massive fluid shift causes hemoconcentration of the cells in the blood. The first action needed is to assess whether the fluid resuscitation at the current rate is adequate. The best ways to determine adequacy by noninvasive measures is by blood pressure measurement and hourly urine output. If fluid resuscitation is adequate, no other action is needed. If blood pressure and urine output indicate fluid resuscitation at the current rate is not adequate, it may need adjustment and the physician should be called.

A patient is brought to the emergency department (ED) with severe burns on the legs and feet. Which factors lead the nurse to believe the patient may have full-thickness burns? Select all that apply. 1. Touch sensation is impaired 2. Blanching with pressure is observed 3. Lack of blanching with pressure is observed 4. Wounds appear mottled white, pink to cherry-red 5. Wounds appear waxy white, dark brown, or charred.

Answer: 1, 3, 5 Touch sensation is impaired due to impaired nerve endings in full-thickness burns. Lack of blanching with pressure is observed, as all skin elements are destroyed. Wounds appear waxy white, dark brown, or charred in full-thickness burns, as all skin elements and local nerve endings are destroyed, and coagulation necrosis is present. Blanching with pressure is observed in partial-thickness burns because varying degrees of both the epidermis and dermis are involved, and skin elements of regeneration are viable. Wounds appear mottled white, pink to cherry-red in a partial-thickness burn.

A patient has been receiving dressing changes with silver sulfadiazine (Silvadene) for burn injuries over both lower arms. The nurse notices that the patient's white blood cell count has dropped significantly over the past 4 days. What may this change indicate? A The patient's infection is improving. B The patient is having an allergic reaction to the silver sulfadiazine. C The patient has kidney disease. D The patient has an electrolyte imbalance

B

It has been 12 hours since a patient has been admitted for burns to the face and neck with associated inhalation injuries. The patient had been wheezing audible and the wheezing has now stopped. What nursing action is appropriate? A. check the pt's SpO2 level B. Notify the physician immediately C. Re-assess breathing in 1 hour D. Document improvement in patient's condition

B

The client with burns to the head, neck, and upper body from a house fire starts drooling uncontrollably about 8 hours after the injury. What is the nurse's best first action? A. Ensure that the client remains NPO. B. Notify the Rapid Response Team. C. Slow the IV infusion rate. D. Raise the head of the bed

B

Which client response does the nurse interpret as an indication of fluid resuscitation adequacy? A Decreasing pulse pressure B Decreasing urine specific gravity C Decreasing core body temperature D Increasing respiratory rate and depth

B

Patients with burns may have mesh grafts or sheet grafts. Which of the following sites is most likely to have a sheet graft applied? a) Arm b) Face c) Leg d) Chest

B A sheet graft is more likely to be used on the face and hands because the cosmetic effects are more optimal. Meshed grafts are more commonly used elsewhere on the body (e.g., arm, leg, chest).

A burn patient in the rehabilitation phase of injury is increasingly anxious and unable to sleep. The nurse should consult with the provider to further assess the patient for a) acute delirium b) PTSD c) suicidal intentions d) bipolar disorder

B Burn-injured patients experience psychologically devastating injuries in addition to physical injuries. Burn patients who demonstrate changes in behavior, anxiety, insomnia, regression, and acting out should be evaluated for posttraumatic stress disorder.

The nurse is caring for a patient who has undergone skin grafting of the face and arms for burn wound treatment. A primary nursing diagnosis is a) altered nutrition, less than body requirements b) body image disturbance c) decreased CO d) fluid volume deficit

B Burns, scarring, and skin grafting can all affect appearance. Body image disturbances may result.

An elderly individual from an assisted-living facility (ALF) presents with severe scald burns to the buttocks and back of the thighs. The caregiver from the ALF accompanies the patient to the emergency department and states that the bath water was "too hot" and that the "patient sat in the water too long." What should the nurse do? a) Ask the caregiver at what temperature the water heater is set in the home. b) Ask the caregiver to step out while examining the patient's burn injury. c) Immediately contact the police to report the suspected elder abuse. d) Ask the caregiver to describe exactly how the injury occurred.

B In cases of suspected abuse, especially in vulnerable patients such as children, elderly, and mentally impaired, it is important to assess the injured patient separately from the caregiver.

When paramedics notice singed hairs in the nose of a burn patient, it is recommended that the patient be intubated. What is the reasoning for the immediate intubation? a) Carbon monoxide poisoning always occurs when soot is visible. b) Inhalation injury above the glottis may cause significant edema that obstructs the airway. c) The patient will have a copious amount of mucus that will need to be suctioned. d) The singed hairs and soot in the nostrils will cause dysfunction of cilia in the airways.

B In inhalation injury, the airway may become edematous quickly, making intubation difficult. Early intubation is recommended to protect the airway.

The nurse is assisting the patient to select foods from the menu that will promote wound healing. Which statement indicates the nurse's knowledge of nutritional goals? a) "Avoid foods that have saturated fats. Fats interfere with the ability of the burn wound to heal." b) "Choose foods that are high in protein, such as meat, eggs, and beans. These help the burns to heal." c) "It is important to choose foods such as bread and pasta that are high in carbohydrates. These foods will give you energy and help you to heal faster." d) "Select foods that have lots of fiber, such as whole grains and fruits. These will promote removal of toxins from the body that interfere with healing."

B Nutritional therapy must be instituted immediately after burn injury to meet the high metabolic demands of the body. Oral diets should be high in calories and high in protein to meet the demands of the body.

A client was brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to get out of a car fire. The nurse should implement which nursing actions for this client? A) Restrict fluids B) Assess for airway patency C) Administer oxygen as prescribed D) Place a cooling blanket on the client E) Elevate extremities if no fractures are present F) Prepare to give oral pain medication as prescribed

B) Assess for airway patency C) Administer oxygen as prescribed E) Elevate extremities if no fractures are present

The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Base on this level, the nurse would anticipate noting which sign in the client? A) Coma B) Flushing C) Dizziness D) Tachycardia

B) Flushing

The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide most reliable indicator for determining the adequacy? A) vital signs B) UOP C) Mental status D) Peripheral pulses

B) UOP

A nurse who is taking care of a patient with burns is asked by a family member why the patient is losing so much weight. The patient is currently in the intermediate phase of recovery. What would be the nurses most appropriate response to the family member? A)He's on a calorie-restricted diet in order to divert energy to wound healing. B)His body has consumed his fat deposits for fuel because his calorie intake is lower than normal. C)He actually hasnt lost weight. Instead, theres been a change in the distribution of his body fat. D)He lost many fluids while he was being treated in the emergency phase of burn care.

B)His body has consumed his fat deposits for fuel because his calorie intake is lower than normal.

A patients burns have required a homograft. During the nurses most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurses most appropriate response? A)Perform mechanical dbridement to remove the exudate and prevent further infection. B)Inform the primary care provider promptly because the graft may need to be removed. C)Perform range of motion exercises to increase perfusion to the graft site and facilitate healing. D)Document this finding as an expected phase of graft healing.

B)Inform the primary care provider promptly because the graft may need to be removed.

A patient has experienced an electrical burn and has developed thick eschar over the burn site. Which of the following topical antibacterial agents will the nurse expect the physician to order for the wound? A)Silver sulfadiazine 1% (Silvadene) water-soluble cream B)Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream C)Silver nitrate 0.5% aqueous solution D)Acticoat

B)Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream

A home care nurse is performing a visit to a patients home to perform wound care following the patients hospital treatment for severe burns. While interacting with the patient, the nurse should assess for evidence of what complication? A)Psychosis B)Post-traumatic stress disorder C)Delirium D)Vascular dementia

B)Post-traumatic stress disorder

A patient who was burned in a workplace accident has completed the acute phase of treatment and the plan of care has been altered to prioritize rehabilitation. What nursing action should be prioritized during this phase of treatment? A)Monitoring fluid and electrolyte imbalances B)Providing education to the patient and family C)Treating infection D)Promoting thermoregulation

B)Providing education to the patient and family

The nurse is preparing the patient for mechanical dbridement and informs the patient that this will involve which of the following procedures? A)A spontaneous separation of dead tissue from the viable tissue B)Removal of eschar until the point of pain and bleeding occurs C)Shaving of burned skin layers until bleeding, viable tissue is revealed D)Early closure of the wound

B)Removal of eschar until the point of pain and bleeding occurs

In patients with extensive burns, edema occurs in both burned and unburned areas because of a) catecholamine-induced vasoconstriction b) decreased GFR c) increased capillary permeability d) loss of integument barrier

C Capillary permeability is altered in burns beyond the area of tissue damage, resulting in significant shift of proteins, fluid, and electrolytes resulting in edema (third-spacing).

The optimal measurement of intravascular fluid status during the immediate fluid resuscitation phase of burn treatment is a) BUN b) daily weight c) hourly intake and urine output d) serum potassium

C During initial fluid resuscitation, urine output helps guide fluid resuscitation needs. Measuring hourly intake and output is most effective in determining the needs for additional fluid infusion than is urine output alone.

A patient with a 60% burn in the acute phase of treatment develops a tense abdomen, decreasing urine output, hypercapnia, and hypoxemia. Based on this assessment, the nurse anticipates interventions to evaluate and treat the patient for a) AKI b) ARDS c) intra-abdominal hypertension d) DIC disorder

C Intra-abdominal hypertension (IAH) is a serious complication caused by circumferential torso burn injuries or edema from aggressive fluid resuscitation. Signs and symptoms of IAH include tense abdomen, decreased urine output, and worsening pulmonary function.

The nurse is conducting an admission assessment of an 82-year-old patient who sustained a 12% burn from spilling hot coffee on the hand and arm. Which statement is of priority to assist in planning treatment? a) "Do you live alone?" b) "Do you have any drug or food allergies?" c) "Do you have a heart condition or heart failure?" d) "Have you had any surgeries?"

C Many variables influence the outcome of elderly burn patient mortality, including preinjury hydration status, nutritional status, and comorbid diseases, especially heart failure. Assessment questions should include, as a priority, information about the patient's cardiovascular status, including heart failure.

The patient asks the nurse if the placement of the autograft over his full thickness burn will be the only surgical intervention needed to close his wound. The nurse's best response would be: a) "Unfortunately, an autograft skin is a temporary graft and a second surgery will be needed to close the wound." b) "An autograft is a biological dressing that will eventually be replaced by your body generating new tissue." c) "Yes, an autograft will transfer your own skin from one area of your body to cover the burn wound." d) "Unfortunately, autografts frequently do no adhere to burn wounds and a xenograft will be necessary to close the wound."

C The autograft is the only permanent method of grafting, and it uses the patient's own tissue to cover the burn wound.

Tissue damage from burn injury activates an inflammatory response that increases the patient's risk for a) AKI b) ARDS c) infection d) stress ulcers

C The loss of skin as the primary barrier against microorganisms and activation of the inflammatory response cascades results in immunosuppression, placing the patient at an increased risk of infection.

A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50mm/Hg, a pulse rate of 110/beats per minute, and a urine output of 20ml over the past hour. The nurse reports the findings to the health care provider and anticipates which prescription? A) Transfusing 1 unit of packed RBCs B) Administering a diuretic to increase urine output C) Increasing the amount of IV fluid D) Changing the IV LR to 5% dextrose

C) Increasing the amount of IV fluid

The nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which unsafe component of protective isolation technique? A) Using sterile sheets and linens B) Performing strict hand-washing technique C) Wearing gloves and gown only when providing direct care for the client D) Wearing protective garb, including mask, gloves, cap, shoe covers, gowns, and plastic apron

C) Wearing gloves and gown only when providing direct care for the client

A nurse who provides care on a burn unit is preparing to apply a patients ordered topical antibiotic ointment. What action should the nurse perform when administering this medication? A)Apply the new ointment without disturbing the existing layer of ointment. B)Apply the ointment using a sterile tongue depressor. C)Apply a layer of ointment approximately 1/16 inch thick. D)Gently irrigate the wound bed after applying the antibiotic ointment.

C)Apply a layer of ointment approximately 1/16 inch thick.

A patient has experienced burns to his upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action? A)Instruct the patient to keep the wound site in a dependent position. B)Administer PRN analgesia as ordered. C)Assess the patients peripheral pulses distal to the dressing. D)Assist with passive range of motion exercises to set the new dressing.

C)Assess the patients peripheral pulses distal to the dressing.

A nurse is teaching a patient with a partial-thickness wound how to wear his elastic pressure garment. How would the nurse instruct the patient to wear this garment? A)4 to 6 hours a day for 6 months B)During waking hours for 2 to 3 months after the injury C)Continuously D)At night while sleeping for a year after the injury

C)Continuously

A triage nurse in the emergency department (ED) receives a phone call from a frantic father who saw his 4-year-old child tip a pot of boiling water onto her chest. The father has called an ambulance. What would the nurse in the ED receiving the call instruct the father to do? A)Cover the burn with ice and secure with a towel. B)Apply butter to the area that is burned. C)Immerse the child in a cool bath. D)Avoid touching the burned area under any circumstances.

C)Immerse the child in a cool bath.

A client weighing 76 kg is admitted at 0600 with a TBSA burn of 40%. Using the Parkland formula, the client's 24-hour intravenous fluid replacement should be: A. 6,080 mL B. 9,120 mL C. 12,160 mL D. 15,180 mL

C. 12,160 mL

The nurse has just completed the dressing change for a client with burns to the lower legs and ankles. The nurse should place the client's ankles in which position? A. Internal rotation B. Abduction C. Dorsiflexion D. Hyperextension

C. Dorsiflexion

During the rehabilitative phase, the client's burns become infected with pseudomonas. The topical dressing most likely to be ordered for the client is: A. Silver sulfadiazine (Silvadene) B. Poviodine (Betadine) C. Mafenide acetate (Sulfamylon) D. Silver nitrate

C. Mafenide acetate (Sulfamylon)

It has been 12 hours since a patient has been admitted for burns to his face and neck and for inhalation injuries. He had been wheezing audibly, but at this time the nurse notes that his wheezing has stopped. What should the nurse do? A Document this improvement in the patient's condition. B Re-assess his breathing in an hour. C Check the patient's Spo2 level. D Notify the physician immediately.

D

The nurse assesses the wound of a client burned as a result of stepping into a bathtub filled with very hot water. Which assessment finding of the burned areas on the tops of both feet does the nurse use as a basis to document a probable full-thickness injury? A. Most of the wounded area is red. B. The client reports that the area hurts when touched. C. The area does not blanch when firm pressure is applied. D. Thrombosed blood vessels are visible beneath the skin surface.

D

The nurse is managing the pain of a patient with burns. The provider has prescribed opiates to be given intramuscularly. The nurse contacts the provider to change the prescription to IV administration because a) IM injections cause additional skin disruption b) burn pain is so severe it required relief by the fastest route available c) hypermetabolism limits effectiveness of medications administered IM d) tissue edema may interfere w/ drug absorption of injectable routes

D Edema and impaired circulation of the soft tissue interfere with absorption of medications administered subcutaneously or intramuscularly

The nurse is caring for a patient with an electrical injury. The nurse understands that patients with electrical injury are at a high risk for acute kidney injury secondary to a) hypervolemia from burn resuscitation b) increased incidence of ureteral stones c) nephrotoxic antibiotics for prevention of infection d) release of myoglobin from injured tissues

D Myoglobin is released during electrical injury and is a risk factor for rhabdomyolysis and acute kidney injury.

The nurse is planning care to meet the patient's pain management needs related to burn treatment. The patient is alert, oriented, and follows commands. The pain is worse during the day, when various treatments are scheduled. Which statement to the provider best indicates the nurse's knowledge of pain management for this patient? a) "Can we ask the music therapist to come by each morning to see if that will help the patient's pain?" b) "The patient's pain is often unrelieved. I suggest that we also add benzodiazepines to the opioids around the clock." c) "The patient's pain is often unrelieved. It would be best if we can schedule the opioids around the clock." d) "The patient's pain varies depending on the treatment given. Can we try patient-controlled analgesia to see if that helps the patient better?"

D Patient-controlled analgesia allows the patient with burns to self-medicate for pain, thus providing independence with pain management strategies. Nonpharmacological pain strategies may provide helpful adjuncts to pain interventions. Scheduled pain medications and anxiolytic agents, although helpful, do not put the control of pain management with the patient.

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 this client? A) 100% O2 via an arousal mask B) Oxygen via nasal cannula 6L/minute C) Oxygen via nasal cannula at 15L/minute D) 100% Oxygen via a tight-fitting NRB face mask

D) 100% Oxygen via a tight-fitting NRB face mask

A nurse is caring for a patient who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis? A)Activity Intolerance B)Anxiety C)Ineffective Coping D)Acute Pain

D)Acute Pain

A patient is brought to the ED by paramedics, who report that the patient has partial-thickness burns on the chest and legs. The patient has also suffered smoke inhalation. What is the priority in the care of a patient who has been burned and suffered smoke inhalation? A)Pain B)Fluid balance C)Anxiety and fear D)Airway management

D)Airway management

A nurse is performing a home visit to a patient who is recovering following a long course of inpatient treatment for burn injuries. When performing this home visit, the nurse should do which of the following? A)Assess the patient for signs of electrolyte imbalances. B)Administer fluids as ordered. C)Assess the risk for injury recurrence. D)Assess the patients psychosocial state.

D)Assess the patients psychosocial state.

The nurse caring for a patient who is recovering from full-thickness burns is aware of the patients risk for contracture and hypertrophic scarring. How can the nurse best mitigate this risk? A)Apply skin emollients as ordered after granulation has occurred. B)Keep injured areas immobilized whenever possible to promote healing. C)Administer oral or IV corticosteroids as ordered. D)Encourage physical activity and range of motion exercises.

D)Encourage physical activity and range of motion exercises.

A patient is brought to the emergency department from the site of a chemical fire, where he suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the patients arm? A)Superficial partial-thickness B)Deep partial-thickness C)Full partial-thickness D)Full-thickness

D)Full-thickness

A nurse is caring for a patient with burns who is in the later stages of the acute phase of recovery. The plan of nursing care should include which of the following nursing actions? A)Maintenance of bed rest to aid healing B)Choosing appropriate splints and functional devices C)Administration of beta adrenergic blockers D)Prevention of venous thromboembolism

D)Prevention of venous thromboembolism

While performing a patients ordered wound care for the treatment of a burn, the patient has made a series of sarcastic remarks to the nurse and criticized her technique. How should the nurse best interpret this patients behavior? A)The patient may be experiencing an adverse drug reaction that is affecting his cognition and behavior. B)The patient may be experiencing neurologic or psychiatric complications of his injuries. C)The patient may be experiencing inconsistencies in the care that he is being provided. D)The patient may be experiencing anger about his circumstances that he is deflecting toward the nurse.

D)The patient may be experiencing anger about his circumstances that he is deflecting toward the nurse.

An emergency department nurse has just admitted a patient with a burn. What characteristic of the burn will primarily determine whether the patient experiences a systemic response to this injury? A)The length of time since the burn B)The location of burned skin surfaces C)The source of the burn D)The total body surface area (TBSA) affected by the burn

D)The total body surface area (TBSA) affected by the burn

An occupational health nurse is called to the floor of a factory where a worker has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to cool the burn. How should the nurse cool the burn? A)Apply ice to the site of the burn for 5 to 10 minutes. B)Wrap the patients affected extremity in ice until help arrives. C)Apply an oil-based substance or butter to the burned area until help arrives. D)Wrap cool towels around the affected extremity intermittently.

D)Wrap cool towels around the affected extremity intermittently.

The correct priority order of actions in prehospital primary survey for burn injuries is: a) assess ABCs and cervical spine b) provide oxygen therapy if smoke inhalation is suspected c) make rapid head-to-toe assessment to rule out additional trauma d) stop the burning process and prevent further injury

D, A, B, C Early care has a positive impact on recovery. The first priority is to stop the burning process and prevent further injury. At this point, you initiate the primary survey, which is to assess the ABCs and cervical spine. Oxygen therapy follows the ABCs. The secondary survey includes further assessment for additional injuries.

An African American client is admitted with full thickness burns over 40% of his body. In addition to the CBC and complete metabolic panel, the physician is likely to request which additional blood-work? A. Erythrocyte sedimentation rate B. Indirect Coombs C. C reactive protein D. Sickledex

D. Sickledex

An emergency department nurse is performing an assessment on a client who has sustained circumferential burns on both legs. Which assessment would be the priority in caring for this client? a) assessing peripheral pulses b) assessing neurological status c) assessing urine output d) assessing blood pressure

a) assessing peripheral pulses

A nurse is developing a care plan for a client with a circumferential burn injury of the extremity. The nursing diagnosis states Ineffective Tissue Perfusion. Which nursing intervention would the nurse include in the plan of care for the client? a) monitor peripheral pulses every hour b) keep the extremities in a dependent position c) document any changes that occur in the pulse d) place pressure dressings and wraps around the burn sites

a) monitor peripheral pulses every hour

Thermal Injury The 4-year-old child sustains a deep partial-thickness burn. Based on an understanding of growth and development, the nurse anticipates which hospital experiences will probably be the MOST upsetting to the child? a. Intramuscular (IM) Injections. b. Daily examination by the health care provider. c. Taking oral medication when a parent is not there. d. Having the nurse say "no" to requests.

a. CORRECT - a 4-year-old child has many fears, particularly a fear of mutilation; injections would probably be the most upsetting experience for a 4-year-old; encourage understanding by playing with puppets, dolls; demonstrate equipment; talk at child's eye level; administer medication IV b. the child will be more concerned about the injections c. not perceived as scary d. may cause the child frustration but will not contribute to fears

Thermal Injury The nurse monitors the client who experienced partial-and full-thickness burns over the lower extremities 24 hours ago. Which signs should the nurse look for during this phase of burn injury? a. Decreased urinary output b. Increased blood pressure c. Decreased potassium and sodium levels d. Decreased hematocrit level

a. CORRECT - in the emergent phase of burn injury, blood is shunted away from the kidneys; this results in decreased urinary output; transfer of energy from a heat source to the body causes burns; there are three classifications of burn depth. With superficial partial-thickness burns (first-degree), the epidermis is affected (destroyed or injured) and there is painful, red, dry, or minimal or no edema; with deep partial-thickness burns (second-degree), the epidermis and part of the dermis is affected and there is painful, red, blistered edema that exudes fluid; with full thickness burns (third-degree), there is total destruction of the epidermis, entire dermis, and in some cases subcutaneous tissue, muscle, or bone; there is painless, dry, and leathery edema that varies in color (white, red, brown, charred); third-degree burns include symptoms of shock, and probable hematuria and hemolysis b. blood pressure usually decreases due to large fluid shifts c. dehydration and the massive cellular trauma associated with burns cause potassium excess, sodium deficits, and base bicarbonate deficits d. During the emergent phase, the hematocrit increases due to hemoconcentration from large fluid shifts

Thermal Injury The nurse instructs a client with a full thickness burn injury of the legs about an appropriate diet. The nurse determines teaching is successful if the client selects which menu? a. Meat and orange juice b. Whole grain bread and an apple c. Green vegetables and milk d. Peanut butter and a banana

a. CORRECT - includes both meat, which is an excellent source of protein, and orange juice, which is an excellent source of vitamin C; protein is necessary to offset the catabolism caused by the burn and to promote healing; vitamin C also promotes wound healing b. deficient in complete protein and vitamin C c. contains some protein d. contains protein but lacks vitamin C

Thermal Injury The nurse assesses a client who sustained a burn injury. The nurse is MOST concerned if which observation is made? a. The client has singed nasal hair. b. The client's blood pressure is 106/62. c. The client has blisters on the hands. d. The client's capillary refill time is less than 3 seconds.

a. CORRECT - intraoral burns and singed nasal hairs indicate potentially serious injuries; observe client for progressive hoarseness, brassy cough, drooling or exhibiting difficulty swallowing, crowing, wheezing, or stridor b. within normal limits; assess for shock, which occurs during emergent phase c. deep partial thickness burns; client may have burns of various thickness d. within normal limits; as tissue perfusion decreases, capillary refill time will become more sluggish or absent

Thermal Injury The client spilled boiling water on the chest and arms. The nurse in the emergency department assesses the client. The client's skin appears red, moist, and very painful to touch. Fluid filled vesicles are present. Which statement BEST describes the depth of the burn injury? a. This is an insignificant injury. b. A deep partial-thickness burn is present. c. A superficial partial-thickness burn is present. d. A full-thickness burn is present.

a. Hot liquids are a common source of thermal burn injury, painful and need treatment. b. Erythema, pain, and moderate swelling characterize deep partial-thickness burns involve the epidermis. They are very painful due to injury or exposure of the nerve endings. There is mild to moderate edema present and vesicles are present if not previously ruptured. d. In full-thickness to deep thickness burns, all skin elements are destroyed. The area is not painful because the nerves for pain sensation have been destroyed. Thrombosed vessels are often seen and nerves, tendons, muscles, and bone can also be involved.

Thermal Injury The client spilled boiling water on the chest and arms. The nurse in the emergency department assesses the client. The client's skin appears red, moist, and very painful to touch. Fluid filled vesicles are present. Which statement BEST describes the depth of the burn injury? a. This is an insignificant injury. b. A deep partial-thickness burn is present. c. A superficial partial-thickness burn is present. d. A full-thickness burn is present.

a. Hot liquids are a common source of thermal burn injury, painful and need treatment. b. Erythema, pain, and moderate swelling characterize deep partial-thickness burns. No vesicles are initially present. c. CORRECT - Superfical partial-thickness burns involve the epidermis. They are very painful due to injury or exposure of the nerve endings. There is mild to moderate edema present and vesicles are present if not previously ruptured. d. In full-thickness to deep thickness burns, all skin elements are destroyed. The area is not painful because the nerves for pain sensation have been destroyed. Thrombosed vessels are often seen and nerves, tendons, muscles, and bone can also be involved.

Thermal Injury A client reports dyspnea the third day after a major burn episode. The client has rhonchi in both lower lung fields, the urine output is 125 mL/hr, and the CVP is 14 mm Hg (19 cm of water). The nurse interprets this data with which MOST correct statement? a. The client is developing shock. b. The client is in the remobilization phase. c. The client is returning to normal. d. The client is developing hypostatic pneumonia.

a. Shock is a characteristic of the first 24 to 48 hours following a thermal injury. CVP and urine output decrease when a person is in shock. Normal CVP is 2 to 8 mm Hg (3 to 11 cm of water). b. CORRECT - Approximately 48 hours following a thermal injury, the capillary permeability stabilizes and the interstitial fluid shifts back in the vascular compartment. The client then becomes hypervolemic and data for this client indicate this is happening. Signs and symptoms include a slightly increased bounding pulse, increased respiratory rate with shortness of breath, crackles on auscultation, jugular vein distention, and a decreased hematocrit and BUN. c. These findings indicate the client is becoming hypervolemic. d. Rhonchi could indicate the development of hypostatic pneumonia. However, this is not the best interpretation given the other data.

Thermal Injury The nurse cares for an adolescent diagnosed with a superficial partial-thickness burn. Which finding does the nurse expect? a. The client's skin is very red and tender without blisters. b. The client's skin has very painful blisters. c. The client's skin has white and dry burns with no blisters. d. The client's skin has white and dry burns with blisters.

a. This describes a superficial burn injury, such as a sunburn. b. CORRECT - with a superficial partial-thickness burn, up to 1/3 of the epidermis is injured or destroyed. It is painful, red, and dry with little or no edema. c. This describes a full-thickness burn injury. d. Burns with white areas and are dry will not have blisters.

Thermal Injury A nurse assesses a client who sustained a burn injury. The burn area is blistered and painful. Which classification BEST describes the burned area? a. Third degree b. Full thickness c. Superficial partial-thickness d. Deep partial-thickness

a. This is the former name for full thickness burns. b.Full thickness burns present in a variety of colors: red, white, brown, yellow, black in color. There is severe edema present with eschar. No pain or blisters are present. c. CORRECT - Superficial partial-thickness are red in color, have mild edema present, are painful, and blisters are present d. Deep partial-thickness are white to red in color and are painful. The burn is deeper than 1/3 of the dermis and there is moderate edema, but without blisters.

Thermal Injury The client sustains burns to the anterior portion of both upper extremities, trunk, and right leg. The nurse uses the Rule of Nines to estimate the percentage of body surface area burned. Which is the correct percentage? a. 23% b. 36% c. 45% d. 54%

a. Too low a percentage b. CORRECT - only the front portions of the arms, trunk and right leg are burned; thus, the calculation is 4.5% for each arm, 18% for the trunk, and 9% for the front of one leg; Rule of Nines estimates the surface burned; transfer of energy from a heat source to the body causes burns; there are three classifications of burn depth; with superficial partial-thickness burns (first-degree), the epidermis is affected (destroyed or injured) and there is painful, red, dry, or minimal or no edema; with deep partial-thickness burns (second-degree), the epidermis and part of the dermis is affected and there is painful, red, blistered edema that exudes fluid [with full thickness burns (third-degree), there is total destruction of the epidermis, entire dermis, and in some cases subcutaneous tissue, muscle, or bone; there is painless, dry, and leathery edema that varies in color (white, red, brown, black, charred); third-degree burns include symptoms of shock, and probable hematuria and hemolysis c. too high a percentage d. too high

Carbon Monoxide Poisoning The nurse admits the client who was asleep in an upstairs bedroom that became smoky during a home fire. The client now complains of headache, nausea, and drowsiness, and the client's skin has a red-purple appearance. With which condition should the nurse recognize that these symptoms are usually associated? a. Anxiety following a catastrophic event. b. Pulmonary fluid overload. c. Carbon monoxide poisoning. d. Lactic acidosis.

a. anxiety does not cause drowsiness or a change in the color of the client's skin b. signs of pulmonary fluid overload following exposure to smoke are shortness of breath, especially in the supine position, and dyspnea; red-purple appearance to the skin is a characteristic finding associated with carbon monoxide poisoning c. CORRECT - carbon monoxide is a gas that can result from any type of combusition; all clients with inhalation injury are at risk for carbon monoxide poisoning; earlies signs of carbon monoxide poisoning are associated with cerebral hypoxia and include headache, nausea, drowsiness, confusion, and stupor that may progress to coma; carbon monoxide level over 10% will casue symptoms starting from headache and progressing to death by 79%; carbon monoxide poisoning is toxicity from inhaling carbon monoxide (CO) fumes; CO attaches to red blood cell (RBC), creating carboxyhemoglobulin that replaces the oxygen (O2 molecule on the heoglobulin; this decreases the oxygen carrying capacity of the RBC, causing hypoxia; signs and symptoms include headache, dizziness, fatigue, seizures, coma, death, and difficulty concentrating; treatment includes removing causative agent, O2 (possibly even hyperbaric O2), intubation and mechanical ventilation hemodynamic monitoring, monitoring vital signs, decreasing oxygen demands, and symptomatic; client education includes sources of CO, how to avoid these sources, and installing CO detectors in home d. lactic acidosis can cause drowsiness, but it does not result in changes to the appearance of the skin

Thermal Injury Forty-eight hours after the client's burn injury, the nurse notes large amounts of edema in all burned areas. The nurse monitors the client for signs and symptoms of hypovolemic shock. Which is a factor that contributes to the development of hypovolemic shock in the burn client? a. Large urine output b. Decreased insensible fluid loss. c. Decreased hematocrit. d. Increased capillary permeability.

a. as fluid moves out of the vasculature, perfusion to the kidney decreases and urine output falls; adequate fluid replacement is important to maintain kidney perfusion and prevent obstruction of the tubules b. normal insensible loss is 30 to 50 mL/hour (hr), but this may increase to as much as 200 to 400 mL/hr in severely burned clients c. elevated hematocrit is a common problem due to loss of fluid in the intravascular space. This results in hemoconcentration d. CORRECT - massive shift of fluid can occur as capillary permeability increases and fluid moves out of the blood vessels; intravascular volume is depleted, blood pressure decreases, pulse increases, urine output decreases, and edema increases; this may lead to hypovolemic shock; transfer of energy from a heat source to the body causes burns; there are three classifications of burn depth; with superficial partial-thickness burns (first-degree), the epidermis is affected (destroyed or injured) and there is painful, red, dry, or minimal or no edema; with deep partial-thickness burns (second-degree), the epidermis and part of the dermis is affected and there is painful, red, blistered edema that exudes fluid. With full thickness burns (third-degree), there is total destruction of the epidermis, entire dermis, and in some cases subcutaneous tissue, muscle, or bone; there is painless, dry, and leathery edema that varies in color (white, red, brown, black, charred); third-degree burns include symptoms of shock, and probable hematuria and hemolysis

Thermal Injury The client diagnosed with burns on the face and upper arms prepares for discharge. The nurse wants to help ease the client's adjustment back into the community. Which of the nurse's actions would be MOST helpful? a. Discuss the use of make-up to minimize the scars. b. Allow the client to withdraw as needed. c. Persuade the client to view the client face and arms in the mirror. d. Encourage the client to walk in the hall with family members.

a. burns can produce emotional trauma in addition to physical changes; nurse should anticipate the guidance the client needs, and address both physical and emotional changes; other clients who have experienced burns may be able to provide information about camouflage techniques, as well as provide a good role model for the client; they are often a better choice than the nurse for this type of discussion b. social isolation is common in individuals who have experienced a change in body image; it is unwise to allow the client to continue to isolate herself while in the hospital c. denial of the burn injury's effects may be a protective mechanism; client should not be forced to view a disfigurement d. CORRECT - this allows the client to experience the reactions of others while still experiencing the support and guidance of the hospital staff; nurse's encouragement also gives the nurse the opportunity to provide anticipatory guidance through the following stages; stage one is psychological

Thermal Injury A family member brings the client to the emergency department. The client has third-degree burns to the head, neck, chest and right upper extremity. Which nursing intervention is the PRIORITY? a. Insert an intravenous catheter. b. Cover burns with a sterile dressing. c. Establish and maintain a patent airway. d. Administer Lactated Ringer's at 200 mL/hr.

a. establishing access for fluid resuscitation is not the immediate priority b. covering burns is not an immediate priority c. CORRECT - location of this client's burns indicate that it is vital to assess, establish, and maintain an airway; nurse should anticipate the need for intubation or an emergency tracheotomy; first responders to burn injuries should: ensure safety of the first responded, extinguish flames, cool the burn by briefly applying cool water to the burn and clothing covering the burn, remove other clothing, cover the wound to prevent contamination, irrigate chemical burns; and assess ABCs d. fluid resuscitation is not the immediate priority

Thermal Injury The 4-year-old child was sitting near the fireplace when the clothing caught fire and enveloped the child in flames. The nurse was in the home. Which action does the nurse take FIRST? a. Obtains the child's repirations. b. Transports the child to the hospital. c. Pushes the child to the ground and makes the child roll. d. Removes the child's clothing as quickly as possible.

a. first action is to stop the burning process by smothering it; after assessing airway and breathing, remove burned clothing and jewelry b. transport to hospital after emergency care c. CORRECT - smother flames; do not let child run because it will fan the flames d. cover wound with clean cloth and keep victim warm

Thermal Injury The client has a major burn injury. The nurse knows medication is best absorbed which route? a. Intramuscularly b. Orally c. Intravenously d. Topically

a. fluid shift during emergent post-burn phase causes limited absorption from subcutaneous and intramuscular spaces b. oral route not an option because client likely to be in shock c. CORRECT - fluid shift during emergent post-burn phase causes limited absorption from subcutaneous and intramuscular spaces; administer medication prior to painful procedures; keep environment warm to prevent shivering d. peripheral blood vessels have been destroyed so there is poor absorption

Pain The nurse cares for the client diagnosed with partial-thickness and full-thickness burns over 40% of the body. Which nursing action should be ESSENTIAL for the nurse to perform before changing the dressing? a. Administer hyperimmune tetanus. b. Administer analgesics thirty minutes before the procedure. c. Stop tube feedings for at least four hours before the dressing change. d. Weigh the client.

a. hyperimmune tetanus is administered in the emergency room to prevent tetanus infections b. CORRECT - second-degree burns are extremely painful; analgesics should be administered 30 minutes before changing dressings c. tube feedings do not need to be stopped for dressing changes unless it interferes with the procedures; meals should be provided at least one hour after the dressing change d. client should be weighed at the same time each day; it may be done in conjunction with dressing change but it is not essential before the wound care

Thermal Injury Which statement BEST indicates the client understands the long-term rehabilitation (rehab) goals following a severe burn? a. "I need to help the church get the barbecue organized next week." b. "I'll be handing off a lot of my extra activities for awhile." c. "I'm determined to return to 100% function within six months." d. "I guess I'll be out of commission for bowling and baseball."

a. indicates lack of understanding of long-term rehab b. CORRECT - indicates the client understands that rehab will take time, and the client will curtail normal activities for quite awhile c. is not a very realistic goal due to the extent of the burns d. client may need to curtail bowling and baseball for awhile; however, the client may be able to resume these activities after optimal rehab

Thermal Injury The nurse teaches a class on first aid at a community center. Which instruction is the MOST appropriate initial care for a person experiencing an electrical burn? a. Tell the burned person to stop, drop and roll. b. Ensure the burned person has an unobstructed airway. c. Turn off the electrical current. d. Remove the burned person's clothing.

a. initial care for a person with a flame burn b. Important and should be done after it is safe to touch the victim c. CORRECT - rescuer should never touch a person with an electrical burn until the electrical current is turned off; if the current is still on, the rescuer could also be electrocuted; to ensure the safety of a first responder, turn the electrical current off and extinguish any flames; burn care contamination, irrigating any chemical burns, and assessing ABCs d. appropriate for a chemical burn

Thermal Injury The client has burns over approximately 40% total body surface area (TBSA). Which clinical findings suggest that the client is in the shock phase? a. Extreme dryness of the skin, elevated temperature over 104 degrees F (40 degrees C), cardiac dysrhythmias. b. Generalized body edema, tachycardia, dehydration c. Decreased capillary permeability, decreased intracellular fluid, increased intravascular fluid volumes. c. Decreased capillary permeability, decreased intracellular fluid, increased intravascular fluid volumes. d. The shock phase would not start unless total body surface area (TBSA) burned is greater than 50%.

a. lack of skin means thermoregulatory dysfunction and hypothermia b. CORRECT - extensive burns result in generalized body edema in both burned and non-burned tissue, an increased heart rate due to catecholamines release and the hypovolemia, and dehydration due to the evaporative fluid loss; transfer of energy from a heat source to the body causes burns; there are three classifications of burn depth; with superficial partial-thickness burns (first-degree), the epidermis is affected (destroyed or injured and there is painful, red, dry, or minimal or no edema; with deep partial-thickness burns (second-degree), the epidermis and part of the dermis is affected and there is painful, red, blistered edema that exudes fluid; with full thickness burns (third-degree), there is total destruction of the epidermis, entire dermis, and in some cases subcutaneous tissue, muscle, or bone; there is painless, dry, and leathery edema that varies in color (white, red, brown, black, charred); third-degree burns include symptoms of shock, and probable hematuria and hemolysis; burn injury nursing care: administer IV Lactated Ringer's and plasma; use an indwelling catheter to monitor hourly output (which should be at least 30 mL/hour); check for signs of fluid overload versus dehydration; monitor blood pressure, TPR, weight, and serum electrolytes; wound care at least once/day using sterile technique and while wearing cap, gown, mask, and gloves, tetanus prophylaxis; provide a high-caloric, high-carbohydrate, and high-protein diet; use TPN if necessary; administer analgesics 30 mintues before wound care to prevent contractions; administer pain medication intravenously due to impaired circulation and poor absorption; counsel the client regarding change in body image; encourage expression of feelings and demonstrate acceptance of client; evalutae client's readiness to see scarred areas especially facial area); and prepare client for discharge; in an emergency, shock should be aniticpated before it develops; hypovolemia is the most common cause of shock; indications include: increased pulse, decreased blood pressure, pallor, diaphoresis, moist cold skin, oliguria, hyperpnea, metabolic acidosis, altered sensorium; treatment; correct physiologic abnormalities, and restore and maintain tissue perfusion; nursing responsibilities: ensure the client's airway is unobstructed, maintain breathing and circulation, restore the circulating blood volume, insert indwelling catheter, monitor the intake and outtake every 15 to 30 minutes, determine the cause of shock, run lab tests, elevate the client's feet slightly, administer medications as prescribed, maintain body temperature, and have the client avoid too much heat c. fluid loss will lead to decreased intravascular volumes d. could occur when burns are greater than 25% TBSA

Thermal Injury The client suffers a deep thickness burn injury. The nurse cares for the client during the shock phase. The nurse understands which finding is expected during this phase? a. Increased blood pressure b. Decreased urine output c. Hypokalemia d. Decreased pulse

a. the emergent phase (shock phase) of a burn occurs during the first 24-48 hours; fluid is lost through open wounds or extravasation into deeper tissues; blood pressure is decreased b. CORRECT - due to fluid shift during emergent phase, urine output is decreased and urine is concentrated and has a high specific gravity; accurate intake and output is measured and is one of the parameters used to determine the amount of IV fluids; output should be maintained at 30-50 mL/hour c. potassium increased due to tissue destruction and hemolysis of red blood cells d. pulse is increased due to decreased cardiac output

Thermal Injury The nurse cares for the client burned over 45% of the body. Which information is MOST concerning to the nurse? a. A urine output of 75 mL/hr with hemachromagens. b. A pulse rate of 110 beats per minute. c. A mean arterial blood pressure of 75 mm Hg. d. A weight loss of 10% of baseline.

a. urinary output should be 75 to 100 mL/hr if hemachromagens are present, and 30 to 50 mL/hr if hemachromagens are not present b. pulse rate of less than 120 in adults usually indicates adequate intravascular volume c. mean arterial blood pressure should be at least 65 mm Hg in adults during fluid resuscitation d. CORRECT - most people who suffer extensive burns experience an increase in their baseline weight (up to 20% of their pre-burn weight)

An industrial nurse is providing instructions to a group of employees regarding care to a victim in the event of a chemical burn injury. The nurse instructs the employees that the immediate action would be to: a) leave all clothing in place until the client is brought to the emergency department b) remove all clothing, including gloves and shoes c) lavage the skin with water, and avoid brushing powdered chemicals off the clothing to prevent further spread of injury d) determine the antidote for the chemical and place the antidote on the burn site

b) remove all clothing, including gloves and shoes

An emergency department nurse is caring for a client who sustained a burn injury to the anterior arms and anterior chest area. The client sustained the burn from a home fire that occurred in the basement. On assessment of the client, which finding would indicate that the client also sustained a respiratory injury as a result of the burn? a) clear breath sounds b) use of accessory muscles for breathing c) fear and anxiety d) complaints of pain

b) use of accessory muscles for breathing

While monitoring a burn victim, which of the following is considered the 'gold standard' to evaluate burn resuscitation? a. A heart rate less than 120 beats per minute, a blood pressure that is normal to slightly hypertensive and clear lung sounds. b. An adult urine output that is approximately 0.5-1.0ml/kg/hour. c. A pulmonary capillary wedge pressure of less than 18 mm Hg. d. A urinary output has been adequate for 2 hours.

b. An adult urine output that is approximately 0.5-1.0ml/kg/hour

The nurse is assessing an Emergency Room patient for evidence of cardiovascular changes associated with deep and full thickness burns. Which of the following would indicate cardiovascular changes as a result of a serious burn? a. Edema formation can be expected in the burn area as a compensatory process from the microcirculation. b. Hypovolumia, slowed capillary circulation and hyperviscosity are evident. c. Increased tissue perfusion in the wound area to attempt to maintain tissue viability in the affected area. d. Peripheral vasodilation decreases perfusion in the affected area.

b. Hypovolumia, slowed capillary circulation and hyperviscosity are evident

During the rehabilitation phase, the physical healing focuses primarily on wound healing. The burn nurse includes which the following in patient education to assist the patient and family for their return to the community? a.The immune system heals along with the skin and future risk of infection stabilizes. b. The hypermetabolic state lasts from 9-12 months following burn injury and body weight requires carefully monitoring. c. Extensive burn injury decreases the risk for developing bone density changes. d. Thermoregulation disturbances may result in an inability to adjust to changes in environment temperatures.

b. The hypermetabolic state lasts from 9-12 months following burn injury and body weight requires carefully monitoring.

When evaluating the burn extremity for the development of compartment syndrome, which signs and symptoms would alert the nurse to the possibility this has developed?? a.The presence of burn eschar that covers the entire lateral surface of the extremity. b. There is evidence of tautness, decreased capillary refill, coolness and decreased pulses. c. The edema is the area is rapidly dissipating resulting in hypoperfusion to the extremity. d. There is increased discomfort in the affected area.

b. There is evidence of tautness, decreased capillary refill, coolness and decreased pulses.

Which of the following dysfunctions can the nurse anticipate in the burn patient with deep partial or full thickness injury? a. There is retention of the ability of the skin to regulate core temperature. b. There is increased risk of infection due to a loss of integrity of a primary barrier. c. There is a decreased sensitivity to ultraviolet radiation. d. There is maintenance of the ability to absorb Vitamin D.

b. There is increased risk of infection due to a loss of integrity of a primary barrier

A nurse has developed a nursing care plan for a client following a burn injury includes a nursing diagnosis of Deficient Fluid Volume. Which nursing intervention is appropriate to include in the plan of care? a) obtain and record weight every other day b) monitor intake and output every shift c) monitor mental status every hour d) monitor vital signs every 4 hours

c) monitor mental status every hour

The nurse is assessing a patient who has sustained a suspected deep partial thickness burn. In determining if this is a superficial or deep partial thickness injury, the nurse would anticipate which of the following? (Select all that apply.) a. There is no change in capillary refill in the injured extremity. b. Hair follicles, sebaceous glands and epidermal sweat glands are intact. c. The wound appearance is a waxy white, with a wet surface and fluid filled blisters. d. The wound is very painful.

c. The wound appearance is a waxy white, with a wet surface and fluid filled blisters.