PrepU Assignment | Chapter 57 | Management of Patients with Burn Injury

During the recovery of an extensive burn, the client is uncomfortable wearing the tight-fitting custom garment. Which is the best response by the nurse? "The garment can be removed for an hour each day." "A snug fit is needed to minimize scarring and to smooth the skin." "Perhaps the garment should be resized." "The garment acts as a skin layer and prevents infection."

"A snug fit is needed to minimize scarring and to smooth the skin."

A client is scheduled for an allograft to a burn wound, and the client asks for an explanation. What information will the nurse include in the client teaching? "An allograft is a permanent wound covering taken from a donor site in your body." "An allograft is an expensive sheet of skin obtained from a culture." "An allograft is a temporary wound covering obtained from cadaver skin." "An allograft is a temporary wound covering obtained from pig skin."

"An allograft is a temporary wound covering obtained from cadaver skin."

A manufacturing plant has exploded, and the nurse is assigned to triage burn victims as they arrive to the hospital. Which is the most important question for the nurse to ask prior to the arrival of victims? "Are the burns associated with chemicals used in the plant?" "Are any of the victims expected to have electrical burns?" "Are the victims suffering from thermal burns?" "How many victims are anticipated for transport?" SUBMIT ANSWER

"Are the burns associated with chemicals used in the plant?"

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? "I will wear sun block with the highest SPF possible to protect exposed burned skin from the sun." "I will drink a lot of fluids to prevent constipation since I am taking pain medications." "As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help." "I can work with the social worker to find funding assistance programs to help with my medical expenses."

"As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help."

A client with a burn over the lower leg asks why surgery is planned to remove the dead burned tissue. Which response will the nurse make? "It reduces the amount of wound care that you will need as the skin heals." "it encourages your body's natural processes to liquefy any damaged tissue." "It reduces the amount of scarring that will occur on the skin." "It reduces the risk of complications from an infection."

"It reduces the risk of complications from an infection."

A client is cared for in a burn unit after suffering partial-thickness burns. The client's laboratory work reveals a positive wound culture for gram-negative bacteria. The health care provider orders silver sulfadiazine to be applied to the client's burns. The nurse provides information to the client about the medication. Which statement made by the client indicates an understanding about this treatment? Select all that apply. "This medication will help my burn heal." "This medication will be applied directly to the wound." "This medication is an antibacterial." "This medication will stain my skin permanently."

- "This medication will help my burn heal." - "This medication will be applied directly to the wound." - "This medication is an antibacterial."

Which intervention helps to minimize the risk of further injury to an affected person at the scene of a fire? - Place the client with the head positioned slightly below the rest of the body - Cover the client with a wet cloth - Avoid immediate IV fluid therapy - Roll the client in a blanket

- Roll the client in a blanket

A client with a burn wound is prescribed mafenide acetate 5% twice daily. Nursing implications associated with this medication include - protecting the bed linens and client's clothing from contact to prevent staining. - monitoring the client for the development of respiratory acidosis. - monitoring the client's Na+ and K+ serum levels and replace as prescribed. - premedicating the client with an analgesic prior to application.

- premedicating the client with an analgesic prior to application.

When

1%

A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned? 45% 18% 27% 36%

27%

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? 27% 36% 9% 18%

27%

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 increased skeletal muscle breakdown. increased metabolic rate. increased glucose demands. decreased catabolism.

decreased catabolism.

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? allograft silvadene application escharotomy debridement

escharotomy

A client has a burn on the leg related to an engine fire. When the burn area was assessed, it was determined that the client felt no pain in the area and that it appeared leathery. How would the nurse document the depth of burn injury this client has? superficial (first degree) superficial partial-thickness or deep partial-thickness (second degree) full thickness (third degree) fourth degree

full thickness (third degree)

A client who has been burned significantly is taken by air ambulance to the burn unit. What physiologic process furthers a burn injury? intravascular fluid excess hypertension inflammatory neuroendocrine

inflammatory

Which zone of burn injury sustains the most damage? Outer Inner Protective Middle

Inner

A client recovering from burn injuries over both forearms reports itching of the wounds. Which action will the nurse take to enhance the client's comfort? Instruct to pat and not scratch the areas. Elevate the extremities above heart level. Apply warm compresses over the areas. Provide pain medication as needed.

Instruct to pat and not scratch the areas.

A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene? Insert a 20-gauge I.V. catheter and infuse normal saline solution at 150 ml/hour. Irrigate the wounds with water. Do nothing until the chemical agent is identified. Wash the wounds with soap and water and apply a barrier cream.

Irrigate the wounds with water.

Which of the following is the preferred IV fluid for burn resuscitation? Normal saline (NS) Total parenteral nutrition (TPN) Lactated Ringer's (LR) D5W

Lactated Ringer's (LR)

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which IV fluid does the nurse plan to administer first? Dextrose 5% in water (D5W) Albumin Normal saline solution with 20 mEq of potassium per 1,000 ml Lactated Ringer's solution

Lactated Ringer's solution

Which of the following is the analgesic of choice for burn pain? Fentanyl Tylenol with codeine Morphine sulfate Demerol

Morphine sulfate

The nurse determines which statement reflects current research regarding the utilization of nonpharmacological measures in the management of burn pain? Humor therapy has not proven effective in the management of burn pain. Music therapy may provide reality orientation, distraction, and sensory stimulation. Pet therapy has proven effective in the management of burn pain. Music therapy diverts the client's attention toward painful stimulus.

Music therapy may provide reality orientation, distraction, and sensory stimulation.

A client with superficial burns on the face and deep partial-thickness burns on the neck and chest is undergoing treatment and is anxious to know about skin grafting. For which of the following areas can skin grafting be suggested? Face only Face, neck, and chest Face and neck Neck and chest

Neck and chest

A client with a superficial partial-thickness solar burn (sunburn) of the chest, back, face, and arms is seen in urgent care. The nurse's primary concern should be: pain management. infection. body image. fluid resuscitation.

pain management.

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: coagulation. hyperemia. hypotension. stasis.

stasis

Which antimicrobials is not commonly used to treat burns? silver sulfadiazine (Silvadene) mafenide (Sulfamylon) tetracycline silver nitrate (AgNO3) 0.5% solution

tetracycline

A nurse is caring for a client with skin grafts covering full-thickness burns on the arms and legs. During dressing changes, the nurse should: - remove bandages with clean gloves. - wrap elastic bandages distally to proximally on dependent areas. - apply maximum bandages to allow for absorption of drainage. - wrap elastic bandages on the arms and legs, proximally to distally, to promote venous return.

wrap elastic bandages distally to proximally on dependent areas.

To meet early nutritional demands for protein, a 198-lb (90-kg) burned patient will need to ingest a minimum of how much protein every 24 hours? 90 g/day 270 g/day 110 g/day 180 g/day

180 g/day

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? 6 weeks 1 week 2 to 4 weeks 8 weeks

2 to 4 weeks

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? Within 24 hours after surgery As soon as sanguineous drainage is noted Within 12 hours after surgery 2 to 5 days after surgery

2 to 5 days after surgery

A sample consensus formula for fluid replacement recommends that a balanced salt solution be administered in the first 24 hours of a chemical burn in the range of 2 mL/kg/% of burn, with 50% of the total given in the first 8 hours postburn. A 176-lb (80-kg) man with a 30% burn should receive a minimum of how much fluid replacement in the first 8 hours? 4,800 mL 2,400 mL 3,600 mL 1,200 mL

2,400 mL

A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned? 18% 27% 36% 30%

36%

An emergency department nurse is evaluating a client with partial-thickness burns to the entire surfaces of both legs. Based on the rule of nines, what is the percentage of the body burned? 27% 18% 9% 36%

36%

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 urinary output of 100 mL/hr A urinary output of 30 mL/hr A urinary output of 10 mL/hr A urinary output of 80 mL/hr

A urinary output of 30 mL/hr

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? Body temperature readings all within normal limits An electrocardiogram (ECG) showing no arrhythmias A weight gain of 4 lb (2 kg) in 24 hours A urine output consistently above 40 ml/hour

A urine output consistently above 40 ml/hour

A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern? Ca: 9 mg/dL Na+: 145 mEq/L BUN: 28 mg/dL K+: 5.0 mEq/L

BUN: 28 mg/dL

Which of the following skin substitutes is a nylon-silicone membrane coated with a protein? Transcyte Biobrane Integra Mederma

Biobrane

Which of the following measures can be used to cool a burn? Wrapping the person in ice Using cold soaks or dressings for at least 1 hour Application of cool water Application of ice directly to burn

Application of cool water

In a client with burns on the legs, which nursing intervention helps prevent contractures? Elevating the foot of the bed Applying knee splints Hyperextending the client's palms Performing shoulder range-of-motion exercises

Applying knee splints

A client has sustained a severe burn injury and is thought to have an impaired intestinal mucosal barrier. What intervention will best assist in avoiding increased intestinal permeability and prevent early endotoxin translocation? Bowel-cleansing procedures Administration of prophylactic antibiotics Early enteral feeding Administration of stool softeners

Early enteral feeding

Burn shock is characterized by which of the following? Organ hyperperfusion Capillary leak Elevated blood pressure (BP) Severe hypervolemia

Capillary leak

Which complication is common for victims of electrical burns? Hypovolemic shock Inhalation injury Infection Cardiac dysrhythmia

Cardiac dysrhythmia

What quick assessment technique should the nurse use to assess the percentage of burn injury? Observe the color of the client's wound Compare the client's palm with the size of the burn wound Check the client's vital signs Observe the client's level of consciousness

Compare the client's palm with the size of the burn wound Explanation: the palm is approx 1% of patients TBSA

The nurse provides care for a client with a 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 pulses 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? - Document the findings and instruct the client to report numbness of the extremity. Contact the primary care provider and prepare for an escharotomy. Apply an elastic stocking to the extremity and administer SQ heparin per order. Elevate the leg on pillows and reassess the leg in 1 hour.

Contact the primary care provider and prepare for an escharotomy.

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? Hematemesis Fecal occult blood Decreased peristalsis Hyperactive bowel sounds

Decreased peristalsis

When the nurse learns that the client suffered injury from a flash flame, the nurse anticipates which depth of burn? Full thickness Superficial partial thickness Superficial Deep partial thickness

Deep partial thickness

Which type of burn injury involves destruction of the epidermis and upper layers of the dermis as well as injury to the deeper portions of the dermis? Deep partial-thickness Full-thickness Fourth degree Superficial partial thickness

Deep partial-thickness

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? Tracheostomy Escharotomy Ventilator assisted breathing Endotracheal tube insertion

Escharotomy

A client is brought to the ED with burns exceeding 20% of total body surface area. Which is the primary nursing intervention in the care of this client Strict intake and output Endotracheal tube placement Prevent infection Fluid resuscitation

Fluid resuscitation

Skin grafts are necessary for what type of burn? Superficial Full-thickness Superficial partial thickness First degree

Full-thickness

Which type of burn injury requires skin grafting? Deep partial-thickness Superficial partial-thickness Superficial Full-thickness

Full-thickness

A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client? Hyperthyroidism Anemia Cardiac arrest Gastric ulcers

Gastric ulcers

A person suffers leg burns from spilled charcoal lighter fluid. A family member extinguishes the flames. While waiting for an ambulance, what should the burned person do? - Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel. - Sit in a chair, elevate his legs, and have someone cut his pants off around the burned area. - Remove his burned pants so that the air can help cool the wound. - Lie down, have someone cover him with a blanket, and cover his legs with petroleum jelly.

Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel.

A person suffers leg burns from spilled charcoal lighter fluid. A family member extinguishes the flames. While waiting for an ambulance, what should the burned person do? - Remove his burned pants so that the air can help cool the wound. - Sit in a chair, elevate his legs, and have someone cut his pants off around the burned area. - Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel. - Lie down, have someone cover him with a blanket, and cover his legs with petroleum jelly.

Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel.

A nurse provides care for a client with deep partial-thickness burns 48 hours after the burn. What would cause a reduced hematocrit in this client? Hemodilution Hemoconcentration Lack of erythropoietin factor Metabolic acidosis

Hemodilution

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately? Urine output of 70 ml the first hour Complaints of intense thirst Moderate to severe pain Hoarseness of the voice

Hoarseness of the voice

The nurse recognizes that which of the following provide clues about fluid volume status? Select all that apply. Oxygen saturation Skin turgor Percentage of meals eaten Hourly urine output Daily weights

Hourly urine output Daily weights skin turgor

The nurse is caring for a client who has sustained severe burns to 50% of the body. The nurse is aware that fluid shifts during the first week of the acute phase of a burn injury cause massive cell destruction. What should the nurse report if it occurs immediately after burn injury? Hypokalemia Hyperkalemia Hypernatremia Hypercalcemia

Hyperkalemia

The nurse knows that inflammatory response following a burn is proportional to the extent of injury. Which factor presents the greatest impact on the ability to modify the magnitude and duration of the inflammatory response in a client with a burn? Weight Age Family history Preexisting conditions

Preexisting conditions

Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is: Hypocalcemia. Hypernatremia. Hyperkalemia. Hypoglycemia.

Hyperkalemia.

Which of the following is to be expected soon after a major burn? Select all that apply. Anxiety Hypertension Hypotension Bradycardia Tachycardia

Hypotension Bradycardia Anxiety

Which of the following is to be expected soon after a major burn? Select all that apply. Hypotension Tachycardia Bradycardia Hypertension Anxiety

Hypotension Tachycardia Anxiety

The nurse receives a client following a serious thermal burn. Which complication will the nurse take action to prevent first? Hypovolemia Infection Tissue hypoxia Renal failure

Hypovolemia

Which of the following types of shock will a nurse observe in a client with extensive burns? Hypovolemic shock Neurogenic shock Anaphylactic shock Septic shock

Hypovolemic shock

A child tips a pot of boiling water onto his bare legs. The mother should: Cover the child's legs with ice cubes secured with a towel. Liberally apply butter or shortening to the burned areas. Avoid touching the burned skin and take the child to the nearest emergency department. Immerse the child's legs in cool water.

Immerse the child's legs in cool water.

The nurse is providing wound care for a client with burns to the lower extremities. Which topical antibacterial agent carries a side effect of leukopenia that the nurse should monitor for within 48 hours after application? Mafenide (Sulfamylon) Gentamicin sulfate Sulfadiazine, silver (Silvadene) Cerium nitrate solution

Sulfadiazine, silver (Silvadene)

The nurse is caring for a patient who sustained a major burn. What serious gastrointestinal disturbance should the nurse monitor for that frequently occurs with a major burn? Diverticulitis Paralytic ileus Hematemesis Ulcerative colitis

Paralytic ileus

Following a burn injury, the nurse determines which area is the priority for nursing assessment? Nutrition Cardiovascular system Pain Pulmonary system

Pulmonary system

Which of the following fluid or electrolyte changes occur in the emergent/resuscitative phase? Increased urinary output Reduction in blood volume Sodium excess Potassium deficit

Reduction in blood volume

The nurse is caring for a client 48 hours after their burn injury. Which treatment will the nurse anticipate to reduce the client's risk of mortality? Regular bathing of burned areas Remove burned tissue Provide intravenous fluid therapy Administer intravenous antibiotics

Remove burned tissue

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? Acute Pain Risk for Impaired Gas Exchange Altered Tissue Perfusion Infection Risk

Risk for Impaired Gas Exchange

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? Risk for Impaired Gas Exchange Altered Tissue Perfusion Acute Pain Infection Risk

Risk for Impaired Gas Exchange

At the scene of a fire, the first priority is to prevent further injury. What are interventions at the site that can help to prevent injury? Select all that apply. Open a door and encourage air in an enclosed space. Roll the client in a blanket to smother the fire. Place the client in a vertical position. Place the client in a horizontal position.

Roll the client in a blanket to smother the fire. Place the client in a horizontal position.

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? Avoid immediate IV fluid therapy. Cover the client with a wet cloth. Roll the client in a blanket. Place the client with the head positioned slightly below the rest of the body.

Roll the client in a blanket.

A nurse is preparing a care plan for a client burned over 36% of his body 2 days ago. Which clinical manifestation indicates that the client has progressed into the intermediate phase of burn care? The client exhibits metabolic alkalosis. The client's urinary output has fallen below 30 ml/hour. The client's serum sodium levels are elevated. The client's complete blood count readings reflect a reduced hematocrit.

The client's complete blood count readings reflect a reduced hematocrit.

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? The client's urinary output is 0.5 mL/kg/hour. The client's breathing is unlabored and skin is clammy. The client is conscious. The client's heart rate is rapid.

The client's urinary output is 0.5 mL/kg/hour.

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? It helps determine the percentage of the total body surface area (TBSA) that is burned. The early appearance of the burn injury may change. The client's condition is likely to deteriorate after 72 hours. The wound is susceptible to infections.

The early appearance of the burn injury may change.

The open method (exposure method) of burn care, which exposes the burned areas to air, has been virtually abandoned since the advent of effective topical antimicrobials. It is still used on a small scale however. On which areas of the body are burns still being treated this way? Select all that apply. The perineum The face The legs The chest

The perineum The face

Which is the primary reason for placing a client in a horizontal position while smothering flames are present? - To keep fire and smoke from airway - To prevent collapse and further injuries - To promote blood flow to the brain and vital organs - To extinguish flames more quickly

To keep fire and smoke from airway

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? White pulmonary secretions Rectal temperature of 100.4° F (38° C) Urine output of 20 ml/hour Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg

Urine output of 20 ml/hour

When the area of burn is irregular in shape and is scattered over multiple areas of the body, which is the best method for the nurse to obtain a quick assessment of the total body surface area of the burn? Use client's palm size Parkland formula Rule of nines Lund and Browder burns assessment

Use client's palm size

As the first priority of care, a patient with a burn injury will initially need: an indwelling catheter inserted. pain medication administered. fluids replaced. a patent airway established.

a patent airway established.