prepu chapter 66

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 temporary wound covering obtained from cadaver skin."

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%

A client has experienced burns covering the back and front of both legs. Using the Rule of Nines, what percentage would the nurse assign to the client's injury when documenting? Fill in the blank with a number.

36

A client's burns are estimated at 36% of total body surface area; fluid resuscitation has been ordered in the emergency department. After establishing intravenous access, the nurse should anticipate the administration of what fluid?

Lactated Ringer's

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?

Lactated Ringer's solution

In a client who has been burned, which medication should the nurse expect to use to prevent infection?

Mafenide (Sulfamylon)

Which of the following is the analgesic of choice for burn pain?

Morphine sulfate

An emergency department nurse learns from the paramedics that the team is transporting a client who has suffered injury from a scald from a hot kettle. What variables will the nurse consider when determining the depth of burn?

The causative agent

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 total body surface area (TBSA) affected by the burn

A nurse is developing a care plan for a client 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?

To prevent contractures

As the first priority of care, a patient with a burn injury will initially need:

a patent airway established.

During the acute phase of a burn, a nurse should assess:

circulatory status.

Which is a quick technique to assess the percentage of a burn injury?

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

When caring for a client with burns, a nurse should change the wound dressing at least once every:

day.

The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to

decrease catabolism.

A client has received significant electrical burns in a workplace accident. What occurrence makes it difficult to assess internal burn damage in electrical burns?

deep tissue cooling

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:

dislodge the autografts.

Within the burn unit, clients may develop complications based on the type of burn they endured. Which burns have a common complication of cardiac dysrhythmias?

electrical

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

inflammatory

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.

A client has experienced burns to his upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action?

Assess the client's peripheral pulses distal to the dressing

A nurse is performing a home visit to a client 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?

Assess the client's psychosocial state.

A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern?

BUN: 28 mg/dL

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?

Full-thickness

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 should the nurse in the ED receiving the call instruct the father to do?

Immerse the child in a cool bath.

When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority?

Ineffective airway clearance related to edema of the respiratory passages

A client's burns have required a homograft. During the nurse's most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurse's most appropriate response?

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

A client arrives in the emergency department after being burned in a house fire. The client's burns cover the face and the left forearm. What extent of burns does the client most likely have, measured as a percentage?

18

A client has been burned significantly in a workplace accident. Which conditions create the need for intensive care by specifically trained personnel?

All options are correct.

A nurse who provides care on a burn unit is preparing to apply a client's ordered topical antibiotic ointment. What action should the nurse perform when administering this medication?

Apply a layer of ointment approximately 1/16 inch thick

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?

Early enteral feeding

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?

Education about home safety

A nurse practitioner administers first aid to a patient with a deep partial-thickness burn on his left foot. The nurse describes the skin involvement as the:

Epidermis and a portion of deeper dermis.

The nurse in the emergency department receives a patient who sustained a severe burn injury. What is the priority action by the nurse in this situation?

Establish a patent airway.

A client with a burn wound is prescribed mafenide acetate 5% twice daily. Nursing implications associated with this medication include

premedicating the client with an analgesic prior to application.

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 wait for emergency personnel.

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately?

Hoarseness of the voice

Following a burn injury, the nurse determines which area is the priority for nursing assessment?

Pulmonary system

A nurse formulates a nursing diagnosis of Impaired physical mobility for a client with full-thickness burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase?

Related to circumferential eschar

A patient has been prescribed mafenide acetate cream for burn treatment. The nurse should educate the patient regarding which of the following?

Severe burning pain for up to 20 minutes

Which of the following are possible indicators of pulmonary damage from an inhalation injury? Select all that apply.

Singed nasal hair Hoarseness Facial burns

A client 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 client's needs?

A patient-controlled analgesia (PCA) system

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 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?

A urine output consistently above 40 ml/hour

Which complication is common for victims of electrical burns?

Cardiac dysrhythmia

What quick assessment technique should the nurse use to assess the percentage of burn injury?

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

A client with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the client closely for what signs of the onset of burn shock?

Decreased blood pressure

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

A burn client is transitioning from the acute phase of the injury to the rehabilitation phase. The client tells the nurse, "I can't wait to have surgery to reconstruct my face so I look like I used to." What would be the nurse's best response?

"That's something that you and your doctor will likely talk about after your scars mature."

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?

36%

Acticoat antimicrobial barrier dressings used in the treatment of burn wounds can be left in place for which time frame?

5 days

An emergency department 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

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?

Acute Pain

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?

Contact the primary care provider and prepare for an escharotomy.

A client 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 client's arm?

Full thickness

Which type of burn injury requires skin grafting?

Full-thickness

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?

Identification by the destruction of the dermis and epidermis

The nurse is administering an analgesic to a patient with major burns. What is the recommended route for administration for this patient?

Intravenous

Which of the following is the preferred IV fluid for burn resuscitation?

Lactated Ringer's (LR)

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?

Paralytic ileus

Which instruction is the most important to give a client who has recently had a skin graft?

Protect the graft from direct sunlight.

A nurse is aware that after a burn injury and respiratory difficulties have been managed, the next most urgent need is to:

Replace lost fluids and electrolytes.

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?

Roll the client in a blanket.

Leukopenia within 48 hours is a side effect associated with which topical antibacterial agent?

Sulfadiazine, silver (Silvadene)

A patient has a burn injury that has damaged the epidermis. There are no blisters, and the skin is pink in color. This type of burn injury would be documented as which of the following?

Superficial

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 is likely experiencing a delayed onset of respiratory complications

While performing a client's ordered wound care for the treatment of a burn, the client has made a series of sarcastic remarks to the nurse and criticized her technique. How should the nurse best interpret this client's behavior?

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

The nurse cares for a 30-year-old client who suffered severe head and facial burn injuries. Which action, if completed by the client, indicates the client is adapting to altered body image? Select all that apply.

Wears hats and wigs Participates actively in daily activities

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 cool towels around the affected extremity intermittently.

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

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?

escharotomy

Specific potential complications are common to specific types of burns. Which burns can impair ventilation?

face, neck, chest