Med Surg: Chapter 53: Nursing Management: Patients With Burn Injury: PREPU
A client has a third-degree burn on the leg. The wound is being treated by the open method. After about 4 days, a hard crust has formed around the leg and is impairing the circulation to the leg. What procedure would be done to relieve pressure on the affected area? A escharotomy B allograft C debridement D silvadene application
A
A client has undergone grafting following a burn injury. The nurse understands that the first dressing change at the site of an autograft is performed how soon after the surgery? A 2 to 5 days after surgery B As soon as sanguineous drainage is noted C Within 12 hours after surgery D Within 24 hours after surgery
A
A client is brought to the emergency department by a coworker following a burn injury from a high-voltage electrical power line. The triage nurse determines which intervention should be completed first? A Apply a cervical collar on the client B Take the client's vital signs C Insert a urinary Foley catheter D Obtain a 12-lead ECG
A
A critical care nurse frequently provides care on the burns and plastics unit of the hospital. When providing care for patients with recent, extensive burns, the nurse will need to be aware of which cardiovascular alteration that occurs with extensive burns? A Fluid shifting into interstitial spaces B Sequestering of fluid in the capillaries C Increased hemolysis by the spleen D Decreased erythropoiesis
A
A nurse who is contributing to the care of a patient with burns recognizes that the patient's injuries are associated with severe and debilitating pain at nearly all stages of treatment and recovery. What pharmacological intervention is most commonly used in the treatment of burn pain? A Intravenous morphine B Oral codeine C Oral oxycodone D Intravenous hydromorphone (Dilaudid)
A
In a client with burns on the legs, which nursing intervention helps prevent contractures? A Applying knee splints B Hyperextending the client's palms C Elevating the foot of the bed D Performing shoulder range-of-motion exercises
A
The nurse has completed teaching home care instructions to a client being discharged from the burn unit. Which statement from the client indicates the need for further teaching? A "As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help." B "I will wear sun block with the highest SPF possible to protect exposed burned skin from the sun." C "I will drink a lot of fluids to prevent constipation since I am taking pain medications." D "I can work with the social worker to find funding assistance programs to help with my medical expenses."
A
The nurse observes for fluid and electrolyte changes during the acute phase based on the knowledge that fluid remobilization usually begins: A After 48 to 72 hours later, when fluid is moving from the interstitial to the intravascular compartment. B Within the first 24 hours, when massive amounts of fluid are being administered intravenously. C After 10 days, when scar tissue begins to cover the wound and prevent evaporative fluid loss. D After 5 days, when capillary permeability has returned to normal.
A
Which of the following is a disadvantage of surgical debridement? A Bleeding B Contractures C Loss of function D Scarring
A
Which of the following is a potential cause of a superficial partial-thickness burn? A Sunburn B Flash flame C Scald D Electrical current
A
Which type of burn injury requires skin grafting? A Full-thickness B Deep partial-thickness C Superficial partial-thickness D Superficial
A
A nurse provides care for a client with deep partial-thickness burns. What could cause a reduced hematocrit (HCT) in this client? A Hemodilution B Lack of erythropoietin factor C Metabolic acidosis D Hemoconcentration
A Reduced HCT is caused by hemodilution, in which volume overload resulting from interstitial-to-plasma fluid shift lowers the concentration of erythrocytes and other blood elements.
A nurse is required to monitor the effectiveness of fluid resuscitation in a client who is being treated for burns. Which of the following assessments would indicate the success of the fluid resuscitation? A The client's urinary output is 0.3 to 0.5 mL/kg/hour. B The client is alert and conscious. C The client's breathing is unlabored, and skin is clammy. D The client's heart rate is rapid and regular.
A Successful fluid resuscitation is gauged by a urinary output of 0.3 to 0.5 mL/kg/hour via an indwelling catheter. Fluid resuscitation does not directly affect the client's heart rate, breathing, or mental status.
A nurse is aware that after a burn injury and respiratory difficulties have been managed, the next most urgent need is to: A Replace lost fluids and electrolytes. B Monitor cardiac status. C Measure hourly urinary output. D Prevent renal shutdown.
A After managing respiratory difficulties, the next most urgent need is to prevent irreversible shock by replacing lost fluids and electrolytes. The total volume and rate of IV fluid replacement are gauged by the patient's response and guided by the resuscitation formula.
A patient in the emergent/resuscitative phase of a burn injury has had her lab work drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what? A Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis B Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis C Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis D Hypokalemia, hyponatremia, elevated hematocrit, and metabolic alkalosis
A Fluid and electrolyte changes in the emergent/resuscitative phase of a burn injury include hyperkalemia related to the release of potassium into the extracellular fluid, hyponatremia from large amount of sodium lost in trapped edema fluid, hemoconcentration that leads to an increased hematocrit and loss of bicarbonate ions that results in metabolic acidosis.
A client presents with a full-thickness burn to the anterior chest. The leathery skin is tight, making breathing difficult. The nurse anticipates which treatment management technique in the care of this client? A Tracheostomy B Endotracheal tube insertion C Escharotomy D Ventilator assisted breathing
B
A client with deep partial-thickness and full-thickness burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse provides additional client teaching because these exercises may: A increase edema in the arms. B dislodge the autografts. C increase the amount of scarring. D decrease circulation to the fingers.
B
A nurse is providing care to a client who has sustained a major burn injury. When developing the client's plan of care, the nurse anticipates that the greatest amount of fluid shifting would occur at which time? A not before 48 hours after the burn B about 24 hours after the burn C 3 to 5 days after the burn D approximately 1 week after the burn
B
A patient has an electrical burn and has developed thick eschar over the burn wound. Which of the following topical antibacterial agents will the nurse expect the health care provider to order for the wound? A Silver nitrate 0.5% aqueous solution B Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream C Acticoat D Silver sulfadiazine 1% (Silvadene) water-soluble cream
B
A patient has entered the rehabilitative stage of burn treatment and is now receiving extensive health education in preparation for discharge. The patient's plan of care involves the use of elastic pressure garments. What teaching should the nurse provide to the patient about this intervention? A "Your pressure garments will be most effective if you wear them in a cycle of 2 hours on, 2 hours off." B "It's important that you try to keep your pressure garments in place at all times." C "You should plan to wear your pressure garments for 24 hours a day, 5 to 6 days a week." D "Scarring will be best controlled if you remove your pressure garments for 3 to 4 hours each day."
B
Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is: A Hypocalcemia. B Hyperkalemia. C Hypernatremia. D Hypoglycemia.
B
Initial first aid rendered at the scene of a fire includes preventing further injury through heat exposure. Which intervention could contribute to tissue hypoxia and necrosis and therefore should be avoided? A Removal of hair B Application of ice C Removal of clothing D Irrigation of the wound
B
The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories. The nurse recognizes this intervention is to promote A increased skeletal muscle breakdown. B decreased catabolism. C increased metabolic rate. D increased glucose demands.
B
The nurse is applying an occlusive dressing to a burned foot. What position should the foot be placed in after application of the dressing? A Plantar flexion B Adduction C Dorsiflexion D External rotation
B
The nurse is caring for a patient who sustained a deep partial-thickness burn injury 36 hours ago. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to which of the following nursing diagnoses? A Anxiety B Acute pain C Activity intolerance D Impaired nutrition: less than body requirements
B
Which is the primary nursing intervention in the care of a client with burns exceeding 20% of total body surface area? A Endotracheal tube placement B Fluid resuscitation C Prevent infection D Strict intake and output
B
Which of the following skin substitutes is a nylon-silicone membrane coated with a protein? A Transcyte B Biobrane C Integra D Mederma
B
The nurse is documenting an hourly assessment of a patient who is being treated for full-thickness burns to his lower extremities. Assessment has revealed that the patient's abdominal girth is steadily increasing. This is most likely attributable to what pathophysiological process? A Paralytic ileus B Third spacing C Presence of free air under the patient's diaphragm D Bladder distention due to urinary retention
B Fluid shifts into the abdominal cavity causing increased abdominal distention that interferes with pulmonary ventilation. An increase in abdominal girth would be suggestive of third spacing into the peritoneal space. Bladder distention, paralytic ileus, and free air are less likely to cause an increase in abdominal girth.
A patient will be receiving biologic dressings. The nurse understands that biologic dressings, which use skin from living or recently deceased humans, are known by what name? A Autografts B Homografts C Heterografts D Xenografts
B Homografts (or allografts) and xenografts (or heterografts) are also referred to as biologic dressings and are intended to be temporary wound coverage. Homografts are skin obtained from recently deceased or living humans other than the patient. Xenografts consist of skin taken from animals (usually pigs). An autograft uses the client's own skin, which is transplanted from one part of the body to another.
Which of the following measures can be used to cool a burn? A Wrapping the person in ice B Application of cool water C Using cold soaks or dressings for at least 1 hour D Application of ice directly to burn
B Once a burn has been sustained, the application of cool water is the best first-aid measure. Never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes
A patient is recovering from a burn that she experienced 6 weeks earlier. What is a priority in the rehabilitation and predischarge phase of the burn injury? A Infection control B Patient and family education C Monitoring fluid and electrolyte imbalances D Assessing cardiac output
B Patient and family education is a priority in the acute and rehabilitation phases. There should be no fluid and electrolyte imbalances in the rehabilitation phase. Assessing wound healing is an ongoing function, but it is not a priority in the rehabilitation phase. Documenting family support is not a priority in the rehabilitation phase.
A nurse helps a health care provider treat a full-thickness burn on a patient's hand. Prior to treatment, the nurse documents the appearance of the wound as: A Blistered with a mottled red base. B Dry and pale white. C Broken epidermis that is weeping. D Reddened; blanches with pressure.
B The wound appearance for a full-thickness burn would be dry, pale white, leathery, or charred.
The nurse is caring for a patient who sustained a full-thickness burn to his arm when he was scalded with boiling water. How did the nurse determine that the patient's burns are full-thickness burns? A Not associated with edema formation B Identification by the destruction of the dermis and epidermis C Usually very painful because of exposed nerve endings D Classification by the appearance of blisters
B Third-degree (full-thickness) burns involve total destruction of the epidermis and dermis and, in some cases, destruction of underlying tissue. Second-degree burns are associated with blister formation.
Which of the following site is the source of most microbes leading to bacterial infection? A Respiratory tract B Intestinal tract C Mucous membranes D Skin
B When the wound is healing, it must be protected from infection. A primary source of bacterial infection is the patient's intestinal tract, the source of most microbes. The respiratory tract, skin, and mucous membranes are not the source of most microbes.
During the emergent/resuscitative phase of the burn injury, fluid and electrolyte changes are expected and need to be evaluated. Which of the following apply in this scenario? Select all that apply. A Sodium excess B Reduced blood volume C Increased renal blood flow D Metabolic acidosis E Potassium enters the extracellular fluid
B, D, E,
A client receiving emergency treatment for severe burns has just been assessed to establish the burn depth. Why is a nurse asked to reassess the burn depth after 72 hours? A The wound is susceptible to infections. B The client's condition is likely to deteriorate after 72 hours. C The early appearance of the burn injury may change. D It helps determine the percentage of the total body surface area (TBSA) that is burned.
C
A client who has been burned significantly is taken by air ambulance to the burn unit. What physiologic process furthers a burn injury? A neuroendocrine B hypertension C inflammatory D intravascular fluid excess
C
Burn shock is characterized by which of the following? A Severe hypervolemia B Organ hyperperfusion C Capillary leak D Elevated blood pressure (BP)
C
In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client? A A weight gain of 4 lb (2 kg) in 24 hours B Body temperature readings all within normal limits C A urine output consistently above 40 ml/hour D An electrocardiogram (ECG) showing no arrhythmias
C
When using the Palmer method to estimate the extent of the burn injury, the nurse determines the palm is equal to which percentage of total body surface area? A 4 B 3 C 1 D 2
C
The nurse is planning the care of a patient with a major thermal burn. What outcome will the nurse understand will be optimal during fluid replacement? A A urinary output of 100 mL/hr B A urinary output of 80 mL/hr C A urinary output of 30 mL/hr D A urinary output of 10 mL/hr
C For adults, a urine output of 30 to 50 mL per hour is used as an indication of appropriate resuscitation in thermal and chemical injuries, whereas in electrical injuries a urine output of 75 to 100 mL per hour is the goal
A burn patient is brought to the emergency department. The nurse knows that the first systemic event after a major burn injury is what? A Metabolic acidosis B Hypovolemia C Hemodynamic instability D Hypercalcemia
C The initial systemic event after a major burn injury is hemodynamic instability, which results from loss of capillary integrity and a subsequent shift of fluid, sodium, and protein from the intravascular space into the interstitial spaces. The other listed phenomena occur later.
A teenage boy has been brought by ambulance to the emergency department from a house fire in which he has suffered extensive injuries. In addition to burns, early blood tests reveal carbon monoxide poisoning. This assessment finding will be treated by what intervention? A Deep suctioning B Incentive spirometry C Administration of 100% oxygen D Intubation and administration of bronchodilators
C Treatment for carbon monoxide poisoning usually consists of early intubation and mechanical ventilation with 100% oxygen. Administering 100% oxygen is essential to accelerate the removal of carbon monoxide from the hemoglobin molecule. Bronchodilators, suctioning, and incentive spirometry are ineffective.
The nurse participates in a health fair about fire safety. When clothes catch fire, which intervention helps to minimize the risk of further injury to an affected person at a scene of a fire? A Cover the client with a wet cloth. B Place the client with the head positioned slightly below the rest of the body. C Roll the client in a blanket. D Avoid immediate IV fluid therapy.
C When clothing catches fire, the flames can be extinguished if the person drops to the floor or ground and rolls ("stop, drop, and roll"); anything available to smother the flames, such as a blanket, rug, or coat, may be used. The older adult, or others with impaired mobility, could be instructed to "stop, sit, and pat" to prevent concomitant musculoskeletal injuries. The client should not be covered immediately with a wet cloth or kept in any position other than horizontal. However, IV fluid therapy should be administered en route to the hospital.
A child tips a pot of boiling water onto his bare legs. The mother should: A Liberally apply butter or shortening to the burned areas. B Cover the child's legs with ice cubes secured with a towel. C Avoid touching the burned skin and take the child to the nearest emergency department. D Immerse the child's legs in cool water.
D
A client who has sustained burns to the anterior chest and upper extremities is brought to the burn center. During the initial stage of assessment, which nursing diagnosis is primary? A Alteration in Tissue Perfusion B Acute Pain C Risk for Infection D Risk for Impaired Gas Exchange
D
A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem? A Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg B White pulmonary secretions C Rectal temperature of 100.6° F (38° C) D Urine output of 20 ml/hour
D
A nurse knows to assess a patient with a burn injury for gastrointestinal complications. Which of the following is a sign that indicates the presence of a paralytic ileus? A Fecal occult blood B Hyperactive bowel sounds C Hematemesis D Decreased peristalsis
D
A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of their body. What would be the nurse's priority concern in the immediate care of this patient? A Anxiety B Risk of infection C Body image D Fluid status
D
A patient in the emergent/resuscitative phase of a burn injury has had her lab work drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what? A Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis B Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis C Hypokalemia, hyponatremia, elevated hematocrit, and metabolic alkalosis D Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis
D
A patient is being discharged after sustaining a deep-partial thickness burn during a house fire. The patient is asking when the burn will be healed. The nurse understands that this type of burn injury heals within which of the following time frames? A 8 weeks B 1 week C 6 weeks D 2 to 4 weeks
D
Determining the depth of a burn is difficult initially because there are combinations of injury zones in the same location. The area of intermediate burn injury is the zone in which blood vessels are damaged, but tissue has the potential to survive. This is called the zone of: A hyperemia. B hypotension. C coagulation. D stasis.
D
During the recovery of an extensive burn, the client is complaining about wearing the tight-fitting custom garment. Which is the best response by the nurse? A "The garment acts as a skin layer and prevents infection." B "Perhaps the garment should be resized." C "The garment can be removed for an hour each day." D "A snug fit is needed to minimize scarring and overgrowth of skin."
D
Which complication is common for victims of electrical burns? A Infection B Hypovolemic shock C Inhalation injury D Cardiac dysrhythmia
D
Which instruction is the most important to give a client who has recently had a skin graft? A Use cosmetic camouflage techniques. B Apply lubricating lotion to the graft site. C Continue physical therapy. D Protect the graft from direct sunlight.
D
Which intervention helps to minimize the risk of further injury to an affected person at the scene of a fire? A Avoid immediate IV fluid therapy B Cover the client with a wet cloth C Place the client with the head positioned slightly below the rest of the body D Roll the client in a blanket
D
A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following? A Deep partial-thickness B Superficial partial-thickness C Superficial D Full-thickness
D A full-thickness burn involves total destruction of the dermis and extends into the subcutaneous fat. It can also involve muscle and bone. A superficial burn only damages the epidermis. In a superficial partial-thickness burn, the epidermis is destroyed and a small portion of the underlying dermis is injured. A deep partial-thickness burn extends into the reticular layer of the dermis and is hard to distinguish froma full-thickness burn. It is red or white, mottled, and can be moist or fairly dry.
A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body? A 36% B 9% C 18% D 27%
D According to the Rule of Nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the client received burns to his back (18%) and one arm (9%), totaling 27% of his body.
Following a serious thermal burn, which complication will the nurse take action to prevent first? A Infection B Tissue hypoxia C Renal failure D Hypovolemia
D After a burn, fluid from the body moves toward the burned area, which leads to intravascular fluid deficit. Steps must be taken to prevent irreversible hypovolemic shock in the initial stages of treatment.
Which zone of burn injury sustains the most damage? A Outer B Middle C Protective D Inner
D Each burned area has three zones of injury. The inner zone (known as the area of coagulation, where cellular death occurs) sustains the most damage. The middle area, or zone of stasis, includes a compromised blood supply, inflammation, and tissue injury. The outer zone, the zone of hyperemia, sustains the least damage.
A nurse helps a health care provider treat a full-thickness burn on a patient's hand. Prior to treatment, the nurse documents the appearance of the wound as: A Broken epidermis that is weeping. B Reddened; blanches with pressure. C Blistered with a mottled red base. D Dry and pale white.
D The wound appearance for a full-thickness burn would be dry, pale white, leathery, or charred.
A client is brought to the emergency department by a coworker following a burn injury from a high-voltage electrical power line. The triage nurse determines which intervention should be completed first? A Insert a urinary Foley catheter B Obtain a 12-lead ECG C Take the client's vital signs D Apply a cervical collar on the client
D Until it is known that the client has no fractures, it is imperative that a neck collar be applied and remain in place and that the client is log rolled to eliminate the chance of further spinal cord injury. With high-voltage electrical injuries, cervical spine immobilization is a priority until cervical spine injury is ruled out. The other interventions may be completed; however, the priority intervention is to apply the collar.
