test 2-Chapter 26
Which wound assessment characteristics suggest a superficial partial-thickness burn injury? Black-brown coloration Painful blisters Moderate to severe edema Absence of blisters
Painful blisters Characteristics of a superficial partial-thickness burn injury include pink to red coloration, mild to moderate edema, pain, and blisters.A black-brown coloration is more suggestive of full-thickness burn injury. Moderate to severe edema and absence of blisters may be present with deep partial-thickness to full-thickness burn injuries.
A client with burn injuries states, "I feel so helpless." Which nursing intervention is most helpful for this client? Encouraging participation in wound care Encouraging visitors Reassuring the client that he or she will be fine Telling the client that these feelings are normal
Encouraging participation in wound care Encouraging participation in wound care is most helpful in providing the client some sense of control.Encouraging visitors may be a good distraction, but will not help the client achieve a sense of control. Reassuring the client that he or she will be fine is neither helpful nor therapeutic. Telling the client that his or her feelings are normal may be reassuring, but does not address the client's issue of feeling helpless.
A client with burn injuries is admitted. Which priority does the nurse anticipate within the first 24 hours? Range-of-motion exercises Emotional support Fluid resuscitation Sterile dressing changes
Fluid resuscitation During the first 24 hours after a burn injury, the nurse's first priority is to administer fluid resuscitation because fluid does not stay in the vessels after a burn injury.Range-of-motion exercise is not the priority for this client. Although emotional support and sterile dressing changes are important, they are not the priority during the resuscitation phase of burn injury.
Which clinical manifestation is indicative of wound healing for a client in the acute phase of burn injury? Pale, boggy, dry, or crusted granulation tissue Increasing wound drainage Scar tissue formation Sloughing of grafts
Scar tissue formationIndicators of wound healing include the presence of granulation, reepithelialization, and scar tissue formation.Pale, boggy, dry, or crusted granulation tissue is indicative of infection, as are increasing wound drainage and sloughing of grafts. INCORRECT
In assessing a client in the rehabilitative phase of burn therapy, which priority problem does the nurse anticipate? Intense pain Potential for inadequate oxygenation Impaired self-image Potential for infection
mpaired self-image A priority problem of impaired self-image is expected during the rehabilitation phase. During this phase, the client is discharged and his or her life is not the same.A priority problem of impaired self-image is expected. Intense pain and potential for inadequate oxygenation are relevant in the resuscitation phase of burn injury. Potential for infection is relevant in the acute phase of burn injury.
A client with a burn injury due to a house fire is admitted to the burn unit. The client's family asks the nurse why the client received a tetanus toxoid injection on admission. What is the nurse's best response to the client's family member? "The last tetanus injection was less than 5 years ago." "Burn wound conditions promote the growth of Clostridium tetani." "The wood in the fire had many nails, which penetrated the skin." "The injection was prescribed to prevent infection from Pseudomonas."
"Burn wound conditions promote the growth of Clostridium tetani." The nurse's best response is that burn wound conditions promote the growth of Clostridium tetani, and all burn clients are at risk for this dangerous infection. Tetanus toxoid enhances acquired immunity to C. tetani, so this agent is routinely given when the client is admitted to the hospital.Regardless of when the last tetanus injection is given, it is still given on admission to prevent C. tetani. The fact that there were many nails in the wood in the fire is irrelevant. Tetanus toxoid injection does not prevent Pseudomonas infection.
When teaching fire safety to parents at a school function, which advice does the school nurse offer about the placement of smoke and carbon monoxide detectors? "Every bedroom should have a separate smoke detector." "Every room in the house should have a smoke detector." "If you have a smoke detector, you don't need a carbon monoxide detector." "The kitchen and the bedrooms are the only rooms that need smoke detectors."
"Every bedroom should have a separate smoke detector." The school nurse states that every bedroom needs to have a separate smoke detector. All people should be taught to use home smoke detectors and carbon monoxide detectors and to ensure these are in good working order. The number of detectors needed depends on the size of the home.Every room in the house does not need a smoke detector. There should be at least one detector in the hallway of each story, and at least one detector is needed for the kitchen, each stairwell, and each home entrance. Each room that requires a smoke detector should also have a carbon monoxide detector. Carbon monoxide detectors are instrumental in picking up carbon monoxide gas emissions, such as from a defective heating unit.
The nurse is caring for a client who has burns. Which question does the nurse ask the client and family to best assess their coping strategies? "Do you support each other?" How do you plan to manage this situation?" How have you handled similar situations?" Would you like to see a counselor?"
"How have you handled similar situations?" Asking how the client and family have handled similar situations in the past best assesses whether the client's and the family's coping strategies may be effective."Yes-or-no" questions such as "Do you support each other?" are not very effective in extrapolating helpful information. The client and family in this situation probably are overwhelmed and may not know how they will manage. Asking them how they plan to manage the situation does not assess coping strategies. Asking the client and the family if they would like to see a counselor also does not assess their coping strategies.
The nurse is caring for a client who has burns to the face. Which statement by the client requires further evaluation by the nurse? "I am getting used to looking at myself." "I don't know what I will do when people stare at me." "I know that I will never look the way I used to, even after the scars heal." "My spouse does not stare at the scars as much now as in the beginning."
"I don't know what I will do when people stare at me." The statement about not knowing what to do when people stare indicates that the client is not coping effectively. The nurse needs to assist the client in exploring coping techniques. Community reintegration programs can assist the psychosocial and physical recovery of the client with serious burns. Visits from friends and short public appearances before discharge may help the client begin adjusting to this problem.The statement that the client is getting used to looking at himself or herself, the realization that he or she will always look different than before, and stating that the client's spouse does not stare at the scars as much all indicate that the client is coping effectively.
An emergency room nurse cares for a client admitted with a 50% burn injury at 10:00 this morning. The client weighs 90 kg. Using the Parkland formula, calculate the rate at which the nurse should infuse intravenous fluid resuscitation when started at noon. (Record your answer using a whole number.) mL/hr
ANS: 1500 mL/hr The Parkland formula is 4 mL/kg/% total body surface area burn. This client needs 18,000 mL of fluid during the first 24 hours postburn. Half of the calculated fluid replacement needs to be administered during the first 8 hours after injury, and half during the next 16 hours. This client was burned at 10:00 AM, and fluid was not started until noon. Therefore, 9000 mL must be infused over the next 6 hours at a rate of 1500 mL/hr to meet the criteria of receiving half the calculated dose during the first 8 postburn hours.
An emergency room nurse implements fluid replacement for a client with severe burn injuries. The provider prescribes a liter of 0.9% normal saline to infuse over 1 hour and 30 minutes via gravity tubing with a drip factor of 30 drops/mL. At what rate should the nurse administer the infusion? (Record your answer using a whole number and rounding to the nearest drop.) drops/min
ANS: 333 drops/min 1000 mL divided by 90 minutes, then multiplied by 30 drops, equals 333 drops/min.
An emergency room nurse assesses a client who was rescued from a home fire. The client suddenly develops a loud, brassy cough. Which action should the nurse take first? a. Apply oxygen and continuous pulse oximetry. b. Provide small quantities of ice chips and sips of water. c. Request a prescription for an antitussive medication. d. Ask the respiratory therapist to provide humidified air.
ANS: A Brassy cough and wheezing are some of the signs seen with inhalation injury. The first action by the nurse is to give the client oxygen. Clients with possible inhalation injury also need continuous pulse oximetry. Ice chips and humidified room air will not help the problem, and antitussives are not warranted.
A nurse cares for a client with burn injuries. Which intervention should the nurse implement to appropriately reduce the clients pain? a. Administer the prescribed intravenous morphine sulfate. b. Apply ice to skin around the burn wound for 20 minutes. c. Administer prescribed intramuscular ketorolac (Toradol). d. Decrease tactile stimulation near the burn injuries.
ANS: A Drug therapy for pain management requires opioid and nonopioid analgesics. The IV route is used because of problems with absorption from the muscle and the stomach. For the client to avoid shivering, the room must be kept warm, and ice should not be used. Ice would decrease blood flow to the area. Tactile stimulation can be used for pain management.
The nurse assesses a client who has a severe burn injury. Which statement indicates the client understands the psychosocial impact of a severe burn injury? a. It is normal to feel some depression. b. I will go back to work immediately. c. I will not feel anger about my situation. d. Once I get home, things will be normal.
ANS: A During the recovery period, and for some time after discharge from the hospital, clients with severe burn injuries are likely to have psychological problems that require intervention. Depression is one of these problems. Grief, loss, anxiety, anger, fear, and guilt are all normal feelings that can occur. Clients need to know that problems of physical care and psychological stresses may be overwhelming.
A nurse administers topical gentamicin sulfate (Garamycin) to a clients burn injury. Which laboratory value should the nurse monitor while the client is prescribed this therapy? a. Creatinine b. Red blood cells c. Sodium d. Magnesium
ANS: A Gentamicin is nephrotoxic, and sufficient amounts can be absorbed through burn wounds to affect kidney function. Any client receiving gentamicin by any route should have kidney function monitored. Topical gentamicin will not affect the red blood cell count or the sodium or magnesium levels.
A nurse delegates hydrotherapy to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this activity? a. Keep the water temperature constant when showering the client. b. Assess the wound beds during the hydrotherapy treatment. c. Apply a topical enzyme agent after bathing the client. d. Use sterile saline to irrigate and clean the clients wounds.
ANS: A Hydrotherapy is performed by showering the client on a special shower table. The UAP should keep the water temperature constant. This process allows the nurse to assess the wound beds, but a UAP cannot complete this act. Topical enzyme agents are not part of hydrotherapy. The irrigation does not need to be done with sterile saline.
A nurse cares for a client with burn injuries during the resuscitation phase. Which actions are priorities during this phase? (Select all that apply.) a. Administer analgesics. b. Prevent wound infections. c. Provide fluid replacement. d. Decrease core temperature. e. Initiate physical therapy.
ANS: A, B, C Nursing priorities during the resuscitation phase include securing the airway, supporting circulation and organ perfusion by fluid replacement, keeping the client comfortable with analgesics, preventing infection through careful wound care, maintaining body temperature, and providing emotional support. Physical therapy is inappropriate during the resuscitation phase but may be initiated after the client has been stabilized.
A nurse plans care for a client with burn injuries. Which interventions should the nurse implement to preven infection in the client? (Select all that apply.) a. Ask all family members and visitors to perform hand hygiene before touching the client. b. Carefully monitor burn wounds when providing each dressing change. c. Clean equipment with alcohol between uses with each client on the unit. d. Allow family members to only bring the client plants from the hospitals gift shop. e. Use aseptic technique and wear gloves when performing wound care.
ANS: A, B, E To prevent infection in a client with burn injuries the nurse should ensure everyone performs hand hygiene, monitor wounds for signs of infection, and use aseptic technique, including wearing gloves when performing wound care. The client should have disposable equipment that is not shared with another client, and plants should not be allowed in the clients room.
A nurse cares for an older client with burn injuries. Which age-related changes are paired appropriately with their complications from the burn injuries? (Select all that apply.) a. Slower healing time Increased risk for loss of function from contracture formation b. Reduced inflammatory response Deep partial-thickness wound with minimal exposure c. Reduced thoracic compliance Increased risk for atelectasis d. High incidence of cardiac impairments Increased risk for acute kidney injury e. Thinner skin May not exhibit a fever when infection is present
ANS: A, C, D Slower healing time will place the older adult client at risk for loss of function from contracture formation due to the length of time needed for the client to heal. A pre-existing cardiac impairment increases risk for acute kidney injury from decreased renal blood flow, and reduced thoracic compliance places the client at risk for atelectasis. Reduced inflammatory response places the client at risk for infection without a normal response, including fever. Clients with thinned skin are at greater risk for deeper wounds from minimal exposure.
A nurse plans care for a client with burn injuries. Which interventions should the nurse include in this clients plan of care to ensure adequate nutrition? (Select all that apply.) a. Provide at least 5000 kcal/day. b. Start an oral diet on the first day. c. Administer a diet high in protein. d. Collaborate with a registered dietitian. e. Offer frequent high-calorie snacks.
ANS: A, C, D, E A client with a burn injury needs a high-calorie diet, including at least 5000 kcal/day and frequent high-calorie snacks. The nurse should collaborate with a registered dietitian to ensure the client receives a high-calorie and high-protein diet required for wound healing. Oral diet therapy should be delayed until GI motility resumes.
A nurse assesses a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which assessment finding should alert the nurse to a potential complication? a. Partial pressure of arterial oxygen (PaO2) of 80 mm Hg b. Urine output of 20 mL/hr c. Productive cough with white pulmonary secretions d. Core temperature of 100.6 F (38 C)
ANS: B A significant loss of fluid occurs with burn injuries, and fluids must be replaced to maintain hemodynamics. If fluid replacement is not adequate, the client may become hypotensive and have decreased perfusion of organs, including the brain and kidneys. A low urine output is an indication of poor kidney perfusion. The other manifestations are not complications of burn injuries
The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by autocontamination? a. Use a disposable blood pressure cuff to avoid sharing with other clients. b. Change gloves between wound care on different parts of the clients body. c. Use the closed method of burn wound management for all wound care. d. Advocate for proper and consistent handwashing by all members of the staff.
ANS: B Autocontamination is the transfer of microorganisms from one area to another area of the same clients body, causing infection of a previously uninfected area. Although all techniques listed can help reduce the risk for infection, only changing gloves between performing wound care on different parts of the clients body can prevent autocontamination.
A nurse receives new prescriptions for a client with severe burn injuries who is receiving fluid resuscitation per the Parkland formula. The clients urine output continues to range from 0.2 to 0.25 mL/kg/hr. Which prescription should the nurse question? a. Increase intravenous fluids by 100 mL/hr. b. Administer furosemide (Lasix) 40 mg IV push. c. Continue to monitor urine output hourly. d. Draw blood for serum electrolytes STAT.
ANS: B The plan of care for a client with a burn includes fluid and electrolyte resuscitation. Furosemide would be inappropriate to administer. Postburn fluid needs are calculated initially by using a standardized formula such as the Parkland formula. However, needs vary among clients, and the final fluid volume needed is adjusted to maintain hourly urine output at 0.5 mL/kg/hr. Based on this clients inadequate urine output, fluids need to be increased, urine output needs to be monitored hourly, and electrolytes should be evaluated to ensure appropriate fluids are being infused.
A nurse uses the rule of nines to assess a client with burn injuries to the entire back region and left arm. How should the nurse document the percentage of the clients body that sustained burns? a. 9% b. 18% c. 27% d. 36%
ANS: C 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 the back (18%) and one arm (9%), totaling 27% of the body.
The nurse teaches burn prevention to a community group. Which statement by a member of the group should cause the nurse the greatest concern? a. I get my chimney swept every other year. b. My hot water heater is set at 120 degrees. c. Sometimes I wake up at night and smoke. d. I use a space heater when it gets below zero.
ANS: C House fires are a common occurrence and often lead to serious injury or death. The nurse should be most concerned about a person who wakes up at night and smokes. The nurse needs to question this person about whether he or she gets out of bed to do so, or if this person stays in bed, which could lead to falling back asleep with a lighted cigarette. Although it is recommended to have chimneys swept every year, skipping a year does not pose as much danger as smoking in bed, particularly if the person does not burn wood frequently. Water heaters should be set below 140 F. Space heaters should be used with caution, and the nurse may want to ensure that the person does not allow it to get near clothing or bedding.
A nurse assesses a client who has a burn injury. Which statement indicates the client has a positive perspective of his or her appearance? a. I will allow my spouse to change my dressings. b. I want to have surgical reconstruction. c. I will bathe and dress before breakfast. d. I have secured the pressure dressings as ordered.
ANS: C Indicators that the client with a burn injury has a positive perception of his or her appearance include a willingness to touch the affected body part. Self-care activities such as morning care foster feelings of self- worth, which are closely linked to body image. Allowing others to change the dressing and discussing future reconstruction would not indicate a positive perception of appearance. Wearing the dressing will assist in decreasing complications but will not enhance self-perception.
A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first? a. Assess the level of consciousness and pupillary reactions. b. Ascertain the time food or liquid was last consumed. c. Auscultate breath sounds over the trachea and bronchi. d. Measure abdominal girth and auscultate bowel sounds.
ANS: C Inhalation injuries are present in 7% of clients admitted to burn centers. Drooling and difficulty swallowing can mean that the client is about to lose his or her airway because of this injury. Absence of breath sounds over the trachea and bronchi indicates impending airway obstruction and demands immediate intubation. Knowing the level of consciousness is important in assessing oxygenation to the brain. Ascertaining the time of last food intake is important in case intubation is necessary (the nurse will be more alert for signs of aspiration). However, assessing for air exchange is the most important intervention at this time. Measuring abdominal girth is not relevant in this situation.
A nurse cares for a client who has facial burns. The client asks, Will I ever look the same? How should the nurse respond? a. With reconstructive surgery, you can look the same. b. We can remove the scars with the use of a pressure dressing. c. You will not look exactly the same but cosmetic surgery will help. d. You shouldnt start worrying about your appearance right now.
ANS: C Many clients have unrealistic expectations of reconstructive surgery and envision an appearance identical or equal in quality to the preburn state. The nurse should provide accurate information that includes something to hope for. Pressure dressings prevent further scarring; they cannot remove scars. The client and the family should be taught the expected cosmetic outcomes.
After assessing an older adult client with a burn wound, the nurse documents the findings as follows: Vital Signs: HR: 110BPM, BP:112/68, RR: 20, Oxygen SAT: 94%, Pain: 3/10 LAB: RBC:5,000,000; WBC: 10,000; Platelet: 200,000 Wound assessment: Left chest burn wound 3cm X 2.5cm X 0.5cm wound bed pale with surround tissues with edema present Based on the documented data, which action should the nurse take next? a. Assess the clients skin for signs of adequate perfusion. b. Calculate intake and output ratio for the last 24 hours. c. Prepare to obtain blood and wound cultures. d. Place the client in an isolation room.
ANS: C Older clients have a decreased immune response, so they may not exhibit signs that their immune system is actively fighting an infection, such as fever or an increased white blood cell count. They also are at higher risk for sepsis arising from a localized wound infection. The burn wound shows signs of local infection, so the nurse should assess for this and for systemic infection before the client manifests sepsis. Placing the client in an isolation room, calculating intake and output, and assessing the clients skin should all be implemented but these actions do not take priority over determining whether the client has an infection.
A nurse reviews the following data in the chart of a client with burn injuries: Admission Notes 36-year-old female with bilateral leg burns NKDA Health history of asthma and seasonal allergies Wound Assessment Bilateral leg burns present and leather- like appearance. No blisters or bleeding are present. Client rates pain at 2/10 on a scale of 0-10. Based on the data provided, how should the nurse categorize this clients injuries? a. Partial-thickness deep b. Partial-thickness superficial c. Full thickness d. Superficial
ANS: C The characteristics of the clients wounds meet the criteria for a full-thickness injury: color that is black, brown, yellow, white, or red; no blisters; minimal pain; and firm and inelastic outer layer. Partial-thickness superficial burns appear pink to red and are painful. Partial-thickness deep burns are deep red to white and painful. Superficial burns are pink to red and are also painful.
A nurse reviews the laboratory results for a client who was burned 24 hours ago. Which laboratory result should the nurse report to the health care provider immediately? a. Arterial pH: 7.32 b. Hematocrit: 52% c. Serum potassium: 6.5 mEq/L d. Serum sodium: 131 mEq/L
ANS: C The serum potassium level is changed to the degree that serious life-threatening responses could result. With such a rapid rise in potassium level, the client is at high risk for experiencing severe cardiac dysrhythmias and death. All the other findings are abnormal but do not show the same degree of severity; they would be expected in the emergent phase after a burn injury.
A nurse prepares to administer intravenous cimetidine (Tagamet) to a client who has a new burn injury. The client asks, Why am I taking this medication? How should the nurse respond? a. Tagamet stimulates intestinal movement so you can eat more. b. It improves fluid retention, which helps prevent hypovolemic shock. c. It helps prevent stomach ulcers, which are common after burns. d. Tagamet protects the kidney from damage caused by dehydration.
ANS: C Ulcerative gastrointestinal disease (Curlings ulcer) may develop within 24 hours after a severe burn as a result of increased hydrochloric acid production and a decreased mucosal barrier. This process occurs because of the sympathetic nervous system stress response. Cimetidine is a histamine2 blocker and inhibits the production and release of hydrochloric acid. Cimetidine does not affect intestinal movement and does not prevent
A nurse cares for a client with burn injuries from a house fire. The client is not consistently oriented and reports a headache. Which action should the nurse take? a. Increase the clients oxygen and obtain blood gases. b. Draw blood for a carboxyhemoglobin level. c. Increase the clients intravenous fluid rate. d. Gather appropriate equipment and prepare for an emergency airway.
ANS: D Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose effective movement of air. When this occurs, wheezing is no longer heard, and neither are breath sounds. These clients can lose their airways very quickly, so prompt action is needed. The client requires establishment of an emergency airway. Swelling usually precludes intubation. The other options do not address this emergency situation.
The registered nurse assigns a client who has an open burn wound to a licensed practical nurse (LPN). Which instruction should the nurse provide to the LPN when assigning this client? a. Administer the prescribed tetanus toxoid vaccine. b. Assess the clients wounds for signs of infection. c. Encourage the client to breathe deeply every hour. d. Wash your hands on entering the clients room.
ANS: D Infection can occur when microorganisms from another person or from the environment are transferred to the client. Although all of the interventions listed can help reduce the risk for infection, handwashing is the most effective technique for preventing infection transmission.
A nurse cares for a client who has burn injuries. The clients wife asks, When will his high risk for infection decrease? How should the nurse respond? a. When the antibiotic therapy is complete. b. As soon as his albumin levels return to normal. c. Once we complete the fluid resuscitation process. d. When all of his burn wounds have closed.
ANS: D Intact skin is a major barrier to infection and other disruptions in homeostasis. No matter how much time has passed since the burn injury, the client remains at high risk for infection as long as any area of skin is open. Although the other options are important goals in the clients recovery process, they are not as important as skin closure to decrease the clients risk for infection.
A nurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. Which action should the nurse take next? a. Administer furosemide (Lasix). b. Perform chest physiotherapy. c. Document and reassess in an hour. d. Place the client in an upright position.
ANS: D Pulmonary edema can result from fluid resuscitation given for burn treatment. This can occur even in a young healthy person. Placing the client in an upright position can relieve lung congestion immediately before other measures can be carried out. Although Lasix may be used to treat pulmonary edema in clients who are fluid overloaded, a client with a burn injury will lose a significant amount of fluid through the broken skin; therefore, Lasix would not be appropriate. Chest physiotherapy will not get rid of fluid.
When delegating care for clients on the burn unit, which client does the charge nurse assign to an RN who has floated to the burn unit from the intensive care unit (ICU)? Burn unit client who is being discharged after 6 weeks and needs teaching about wound care Recently admitted client with a high-voltage electrical burn A client who has a 25% total body surface area (TBSA) burn injury, for whom daily wound débridement has been prescribed Client receiving IV lactated Ringer's solution at 150 mL/hr
Client receiving IV lactated Ringer's solution at 150 mL/hr An RN float nurse from ICU will be familiar with administration of IV fluids and with signs of fluid overload, such as shortness of breath, and so could be assigned to the client receiving IV lactated Ringer's solution at 150 mL/hr.The client needing teaching about wound care, the client with a high-voltage electrical burn, and the client with a 25% TBSA burn injury all require specialized knowledge about burn injuries and should be assigned to RNs who have experience caring for clients with burn injuries.
The nurse is evaluating the effectiveness of fluid resuscitation for a client in the resuscitation phase of burn injury. Which finding does the nurse correlate with clinical improvement? Blood urea nitrogen (BUN), 36 mg/dL (12.9 mmol/L) Creatinine, 2.8 mg/dL (248 mcmol/L) Urine output, 40 mL/hr Urine specific gravity, 1.042
Clinical improvement based on fluid resuscitation for a burn client correlates with a urine output of between 30 and 50 mL/hr or 0.5 mL/kg/hr.A BUN of 36 mg/dL (12.9 mmol/L) is above normal, a creatinine of 2.8 mg/dL (248 mcmol/L) is above normal, and a urine specific gravity of 1.042 is above normal.
The nurse on a burn unit has just received change-of-shift report about these clients. Which client does the nurse assess first? Adult client admitted a week ago with deep partial-thickness burns over 35% of the body who is reporting pain Firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers, "I can't catch my breath!" An electrician who suffered external burn injuries a month ago and is asking the nurse to contact the health care provider immediately about discharge plans Older adult client admitted yesterday with partial- and full-thickness burns over 40% of the body who is receiving IV fluids at 250 mL/hr
Firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers, "I can't catch my breath!" The nurse first needs to assess the firefighter recently admitted with smoke inhalation. Smoke inhalation and facial burns are associated with airway inflammation and obstruction. The client with difficulty breathing needs immediate assessment and intervention.Although the client admitted a week ago with deep partial-thickness burns is reporting pain, this client does not require immediate assessment. The electrician who suffered burn injuries a month ago is stable and has been in the burn unit for a month, so the client's condition does not warrant that the nurse should assess this client first. The older adult client admitted yesterday with burns over 40% of the body is stable; he is receiving IV fluids and does not need to be assessed first.
A client with partial-thickness burns of the face and chest caused by a campfire is admitted to the burn unit. The nurse plans to carry out which health care provider request first? Give oxygen per facemask. Infuse lactated Ringer's solution at 150 mL/hr. Give morphine sulfate 4 to 10 mg IV for pain control. Insert a 14 Fr retention catheter.
Give oxygen per facemask. The nurse needs to first administer oxygen per face mask to the client. Facial burns are frequently associated with upper airway inflammation. Administration of oxygen will assist in maintaining the client's tissue oxygenation at an optimal level.Although fluid hydration and pain control are important, the nurse's first priority is the client's airway. Monitoring output is important, but the nurse's first priority is the client's airway.
The nurse is reviewing the health history for an older adult client recently admitted to the burn unit with severe burns to the upper body from a house fire. The nurse plans to contact the health care provider if the client's history reveals which condition? Heart failure Diverticulitis Hypertension Emphysema
Heart failure The nurse will contact the health care provider if the client's history reveals specific information about cardiac or kidney problems, chronic alcoholism, substance abuse, or diabetes mellitus. Any of these problems can influence fluid resuscitation. A client's health history, including any preexisting illnesses, must be known for appropriate management. The stress of a burn injury can make a mild disease process worsen. In older clients, especially those with cardiac disease, a complicating factor in fluid resuscitation may be heart failure or myocardial infarction.Diverticulitis, hypertension, and emphysema are important to be aware of in guiding treatment options. However, heart failure is the main concern when attempting to optimize this older client's fluid resuscitation.
To position a client's burned upper extremities appropriately, how does the nurse position the client's elbow? In a neutral position In a position of comfort Slightly flexed Slightly hyperextended
In a neutral position The neutral (extended) position is the correct placement of the elbow to prevent contracture development.Placing the elbow in a position of comfort is not the best placement because the client then usually wants to flex the joint, which increases the risk for contracture development. The slightly flexed position increases the risk for contracture development. The slightly hyperextended position is not indicated and can be painful.
A client is in the resuscitation phase of burn injury. Which route does the nurse use to administer pain medication to the client? Intramuscular Intravenous Sublingual Topical
Intravenous During the resuscitation phase, the intravenous (IV) route is used for giving opioid drugs because of problems with absorption from the muscle and stomach.When these agents (opioid drugs) are given by the intramuscular or subcutaneous route, they remain in the tissue spaces and do not relieve pain. In addition, when edema is present, all doses are rapidly absorbed at once when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics. The sublingual route may not be effective, and because the skin is too damaged, the topical route is not indicated for administering drugs to the client in the resuscitation phase of burn injury.
A nurse cares for a client with burn injuries who is experiencing anxiety and pain. Which nonpharmacologic comfort measures should the nurse implement? (Select all that apply.) a. Music as a distraction b. Tactile stimulation c. Massage to injury sites d. Cold compresses e. Increasing client control
Nonpharmacologic comfort measures for clients with burn injuries include music therapy, tactile stimulation, massaging unburned areas, warm compresses, and increasing client control.
Which factors indicate that a client's burn wounds are becoming infected? Dry, crusty granulation tissue Elevated blood pressure Hypoglycemia Edema of the skin around the wound Tachycardia
Pale, boggy, dry, or crusted granulation tissue is a sign of infection, as is swelling or edema of the skin around the wound. Tachycardia is a systemic sign of infection.Hypotension, not elevated blood pressure, and hyperglycemia, not hypoglycemia, are systemic signs of infection.
A nursing student is caring for a client with open-wound burns. Which nursing interventions does the nursing student provide for this client? Select all that apply. Provides cushions for comfort Performs frequent hand washing Places plants in the client's room Performs gloved dressing changes Uses disposable dishes
Performs frequent hand washing, performs gloved dressing changes, uses disposable dishes. Frequent hand washing is the most effective technique for preventing infection. Gloves should be worn when changing dressings to reduce the risk for infection. Equipment is not shared with other clients to prevent the risk for infection. Disposable items (e.g., pillows, dishes) are used as much as possible.Cushions are difficult to clean and may harbor organisms, and so are not provided. To avoid exposure to Pseudomonas, having plants or flowers in the room is prohibited.
A client is in the acute phase of burn injury. For which action does the nurse decide to coordinate with the registered dietitian? Discouraging having food brought in from the client's favorite restaurant Providing more palatable choices for the client Helping the client maintain a desirable weight Planning additions to the standard nutritional pattern
Planning additions to the standard nutritional pattern Consultation with the dietitian is required to help the client achieve the correct nutritional balance. Nutritional requirements for the client with a large burn area can exceed 5000 kcal/day. In addition to a high calorie intake, the burn client requires a diet high in protein for wound healing.It is fine for the client with a burn injury to have food brought in from the outside. The hospital kitchen can be consulted to see what other food options may be available to the client. It is not therapeutic for the client with burn injury to lose weight
A newly admitted client has deep partial-thickness burns. The nurse expects to see which clinical manifestations? Red and white wounds with mild pain to palpation Painless, brownish yellow eschar Painful reddened blisters Black skin with eschar and no pain
Red and white wounds with mild pain to palpation A red and white wound bed characterizes deep partial-thickness burns. Blisters are rare. Pain is less than with other types of burns because nerve endings are affected.Painless, brownish yellow eschar characterizes a full-thickness burn. A painful reddened blister is seen with a superficial partial-thickness burn. Painless black skin with eschar is seen in a deep full-thickness burn.
The nurse is caring for a client with a burn injury who is receiving silver sulfadiazine (Silvadene) to the burn wounds. Which best describes the goal of topical antimicrobials? Reduction of bacterial growth in the wound and prevention of systemic sepsis Prevention of cross-contamination from other clients in the unit Enhanced cell growth Reduced need for a skin graft
Reduction of bacterial growth in the wound and prevention of systemic sepsis The best description of the goal of topical antimicrobials such as silver sulfadiazine is that they help prevent infection in burn wounds.Topical antimicrobials such as silver sulfadiazine do not prevent cross-contamination from other clients in the unit. They do not enhance cell growth, nor do they minimize the need the need for a skin graft.
Which assessment information about a 60-kg client admitted 12 hours ago with a full-thickness burn over 30% of the total body surface area is of greatest concern to the nurse? Bowel sounds are absent. The pulse oximetry level is 91%. The serum potassium level is 6.1 mEq/L (6.1 mmol/L). Urine output since admission is 370 mL.
The serum potassium level is 6.1 mEq/L (6.1 mmol/L). The greatest concern for the nurse is to notice an elevated serum potassium level that can cause cardiac dysrhythmias and arrest.Absence of bowel sounds, a pulse oximetry level of 91%, and urine output of 370 mL since admission are normal findings during the resuscitation phase of burn injury.
The client is a burn victim who is noted to have increasing edema and decreased urine output as a result of the inflammatory compensation response. What does the nurse do first? Administer a diuretic. Provide a fluid bolus. Recalculate fluid replacement based on time of hospital arrival. Titrate fluid replacement.
Titrate fluid replacement. The nurse first needs to adjust and titrate the intravenous fluid rate on the basis of urine output plus serum electrolyte values.A common mistake in treatment is giving diuretics to increase urine output. Giving a diuretic will actually decrease circulating volume and cardiac output by pulling fluid from the circulating blood volume to enhance diuresis. Fluid boluses are avoided because they increase capillary pressure and worsen edema. Fluid replacement formulas are calculated from the time of injury, not from the time of arrival at the hospital.
Several clients have been brought to the emergency department after an office building fire. Which client is at greatest risk for inhalation injury? Middle-aged adult who is frantically explaining to the nurse what happened Young adult who suffered burn injuries in a closed space Adult with burns to the extremities Older adult with thick, tan-colored sputum
Young adult who suffered burn injuries in a closed space The client who suffered burn injuries in a closed space is at greatest risk for inhalation injury because the client breathed a greater concentration of confined smoke.Clients who experienced a fire typically have some type of respiratory distress. However, the client talking without difficulty demonstrates minimal respiratory distress. Extensive burns to the hands and face, not the extremities, would be a greater risk. Sputum would be carbonaceous, not tan, if the client had suffered inhalation injury.
