Burns- PrepU

an ED nurse has just received a client with burn injuries brought in by ambulance. the paramedics have started a large-bore IV and covered the burn in cool towels. the burn is estimated as covering 24% of the client's body. how should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period? administer IV fluids administer broad-spectrum antibiotics administer PRBCs administer IV potassium chloride

administer IV fluids

which complication is common for victims of electrical burns? cardiac dysrhythmia hypovolemic shock inhalation injury infection

cardiac dysrhythmia

the nurse is administering an analgesic to a patient with major burns. what is the recommended route for administration for this patient? intravenous intramuscular sub-q oral

intravenous

a nurse is caring for a client 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? ineffective coping acute pain activity intolerance anxiety

acute pain

a client is brought to the ED by paramedics, who report that the client has partial-thickness burns on the chest and legs. the client has also suffered smoke inhalation. what is the priority in the care of a client who has been burned and suffered smoke inhalation? pain airway management fluid balance anxiety and fear

airway management

a triage nurse in the ED received a phone call from a frantic parent who saw their 4 year old child tip a pot of boiling water onto themselves. the parent has called an ambulance. what should the nurse in the ED receiving the call instruct the parent to do? apply butter to the area that is burned immerse the child in a cool bath avoid touching the burned area under any circumstances cover the burn with ice and secure with a towel

immerse the child in a cool bath

the nurse is caring for a client with burns over 55% of total body surface area. which information is essential for the nurse to document to guide the care of this client? SATA current list of medications last meal eaten current body temp last tetanus immunization pre-burn body weight

pre=burn body weight, current list of medications, last tetanus immunization, and current body temp

a client brought to the ED has been exposed to smoke and flames from a house fire. what assessment finding is most important to the nurse in determining care of the client? elevation of BP and HR partial-thickness burns to hands and wrists presence of soot around nasal passages fracture of the fibula with displacement

presence of soot around nasal passages

the nurse is providing education to a client that is scheduled for mechanical debridement of a wound. the nurse knows that mechanical debridement involves which element? shaving of burned skin layers until bleeding, viable tissue is revealed removal of eschar until the point of pain and bleeding occurs early closure of the wound a spontaneous separation of dead tissue from the viable tissue

removal of eschar until the point of pain and bleeding occurs

a nurse is providing discharge teaching for a client with a burn wound on the leg. what instructions are important to give the client? SATA wash the wound with soap and water continue physical therapy exercises apply lubricating lotion to the wound bed report increased redness and wound drainage to the healthcare provider take pain medications daily

report increased redness and wound drainage to the healthcare provider, wash the wound with soap and water, and continue physical therapy exercises

an emergency department nurse has just admitted a client with a burn. what characteristic of the burn will primarily determine whether the client experiences a systemic response to this injury? the source of the burn the length of time since the burn the TBSA affected by the burn the location of burned skin surfaces

the TBSA affected by the burn

a nurse on a burn unit is caring for a client who experienced burn injuries 2 days ago. the client is now showing signs and symptoms of airway obstruction, despite appearing stable since admitted. how should the client's change in status be best understood? the client's respiratory complications are likely related to psychosocial stress the client has likely developed a systemic infection the client is likely experiencing a delayed onset of respiratory complications the client is likely experiencing an anaphylactic reaction to a medication

the client is likely experiencing a delayed onset of respiratory complications

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? wrap the client's affected extremity in ice until help arrives apply ice to the site of the burn for 5-10 minutes wrap cool towels around the affected extremity intermittently apply an oil=based substance to the burned area until help arrives

wrap cool towels around the affected extremity intermittently

The nurse cares for a client with extensive burn injuries. which parameters would the nurse evaluate to determine if the client is receiving adequate fluid resuscitation? SATA heart rate UO O2 sat BP

HR and UO

a client is brought to the ED with a burn injury. the nurse knows that the first systemic event after a major burn injury is what event? hypokalemia gastrointestinal hypermotility hemodynamic instability respiratory arrest

hemodynamic instability

the nurse in the ED receives a patient who sustained a severe burn injury. what is the priority action by the nurse in this situation? administer pain medication replace fluids insert an indwelling catheter establish a patent airway

establish a patent airway

a client has been admitted to a burn ICU with extensive full-thickness burns over 25% of the body. after ensuring cardiopulmonary stability, what would be the nurse's immediate, priority concern when planning this client's care? fluid status risk for infection psychosocial coping nutritional status

fluid status

what quick assessment technique should the nurse use to assess the percentage of burn injury? observe the client's level of consciousness check the VS observe the color of the client's wound compare the client's palm with the size of the burn wound

compare the client's palm with the size of the burn wound

the nurse provides care for a client with full-thickness, circumferential burn of the left lower leg. during the nurse's initial shift assessment, the client is resting and the physical assessment of the left lower extremity is unremarkable. one hour later, the nurse notes the pulseless of the left lower leg cannot be obtained by a doppler ultrasound device, and the capillary refill of the left great toe is greater than 2 seconds. what is the nurse's best response based on the clinical findings? apply an elastic stocking to the extremity and administer Sub-q heparin per order contact the primary care provider and prepare for an escharotomy document the findings and instruct the client to report numbness of the extremity elevate the leg on pillows and reassess the leg in 1 hour

contact the primary care provider and prepare for an escharotomy

the nurse is teaching a client who underwent a skin graft for a burn injury about the use of pressure garments. what instructions should the nurse include in the teaching? SATA massage any moisturizers, lotions, creams, and petroleum-based ointments completely into the skin before donning the garment contact the primary provider if the garment does not seem to fit properly wear the garment at least 12 hours each day machine wash the pressure garment daily with a mild detergent roll the garment and wring tightly to ensure garment is as dry as possible after washing

contact the primary provider if the garment does not seem to fit properly and massage any moisturizers, lotions, creams, and petroleum-based ointments completely into the skin before donning the garment