A3 EX 1 Chapter 62: Management of Patients with Burn Injury -
The nurse cares for a client with superficial partial-thickness burn injuries to the lower extremities. The client is ordered IV morphine for pain. The nurse understands narcotics are given via IV during the initial management of pain because
tissue edema may interfere with drug absorption via other routes. altered tissue perfusion from the burn injury.
Mafedine acetate
Effective even in the presence of eschar absorbed systematically and may produce metabolic acidosis anti-clostridial antibiotic
When using the Palmer method to estimate the extent of a small or scattered burn injury, the nurse recognizes the palm is equal to which percentage of total body surface area? 4 3 2 1
1
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?
2 to 4 weeks
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% 9 each arm 9 back
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? 36% 9% 18% 27%
36%
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
Burn shock is characterized by which of the following? Severe hypervolemia Organ hyperperfusion Capillary leak Elevated blood pressure (BP)
Capillary leak THIRD SPACING OF FLUID
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. Document the findings and instruct the client to report numbness of the extremity. Elevate the leg on pillows and reassess the leg in 1 hour. Apply an elastic stocking to the extremity and administer SQ heparin per order.
Contact the primary care provider and prepare for an escharotomy.
The spouse of a client who was struck by lightning asks the nurse why the areas involved seems so small but the damage is extensive. Which is the best explanation from the nurse? Electrical burns usually follow an internal path. Moisture intensifies the damage inflicted. Lightning is higher in voltage than electricity. The skin is a good conductor of electricity.
Electrical burns usually follow an internal path
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? Deep partial-thickness Superficial partial-thickness Superficial Full-thickness
Full-thickness
Which type of burn injury requires skin grafting? Superficial Superficial partial-thickness Full-thickness Deep partial-thickness
Full-thickness
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 Hoarseness of the voice Moderate to severe pain Complaints of intense thirst
Hoarseness of the voice Hoarseness is indicative of injury to the respiratory system and could indicate the need for immediate intubation.
Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is: Hypocalcemia. Hyperkalemia. Hypoglycemia. Hypernatremia.
Hyperkalemia. hyponatremia (sodium depletion) is present. Immediately after burn injury, hyperkalemia (excessive potassium) results from massive cell destruction
Which of the following is to be expected soon after a major burn? Select all that apply.
Hypotension Tachycardia Anxiety
Dermis
Inner layer of skin
superficial partial thickness burn
Involves the epidermis and the upper portion of the dermis. Involved area may be extremely painful and exhibit blisters. Healing occurs with minimal to no scarring in 5-21 days. he epidermis is destroyed and a small portion of the underlying dermis is injured.
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? Normal saline solution with 20 mEq of potassium per 1,000 ml Albumin Lactated Ringer's solution Dextrose 5% in water (D5W)
Lactated Ringer's solution replaces lost sodium and corrects metabolic acidosis, both of which commonly occur following a burn
Catabolism
Metabolic pathways that break down molecules, releasing energy.
Which of the following is the analgesic of choice for burn pain? Tylenol with codeine Demerol Fentanyl Morphine sulfate
Morphine Sulfate It is titrated to obtain pain relief on the patient's self-report of pain.
Epidermis
Outer layer of skin
A client brought to the emergency department has been exposed to smoke and flames from a house fire. What assessment finding is most important to the nurse in determining care of the client? Partial-thickness burns to hands and wrists Fracture of the fibula with displacement Presence of soot around nasal passages Elevation of blood pressure and heart rate
Presence of soot around nasal passages If the client has soot or evidence of carbon about the nasal passages, the nurse should anticipate respiratory difficulties. Edema and swelling of the internal airways may not be present initially but can progress quickly.
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 Related to infection Related to fat emboli Related to femoral artery occlusion
Related to circumferential eschar As edema develops on circumferential burns, eschar forms a tight, constricting band, compromising circulation to the extremity distal to the circumferential site and impairing physical mobility
The client is admitted with full-thickness burns to the forearm. Which is the most accurate interpretation made by the nurse? Skin grafting will be necessary. Pain management will be a challenge. The wound will take up to 3 weeks to heal. Ligaments, tendons, muscles, and bone are not involved.
Skin grafting will be necessary.
An explosion of a fuel tanker has resulted in melting of clothing on the driver and extensive full-body burns. The client is brought into the emergency department alert, denying pain, and joking with the staff. Which is the best interpretation of this behavior? The client has experienced extensive full-thickness burns. The paramedic administered high doses of opioids during transport. The client is in hypovolemic shock. The client has experienced partial-thickness burns.
The client has experienced extensive full-thickness burns. In full-thickness burns, nerves are damaged and consequently painless.
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? The client's condition is likely to deteriorate after 72 hours. The wound is susceptible to infections. 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 early appearance of the burn injury may change.
In a client with burns on the legs, which nursing intervention helps prevent contractures? Hyperextending the client's palms Performing shoulder range-of-motion exercises Elevating the foot of the bed The early appearance of the burn injury may change.
The early appearance of the burn injury may change.
Palmer method
Use palm to estimate size of burn 1%
full thickness burn
a burn in which all the layers of the skin are damaged. There are usually areas that are charred black or areas that are dry and white. Also called a third-degree burn. total destruction of the dermis and extends into the subcutaneous fat. It can also involve muscle and bone
superficial burn FIRST DEGREE
a burn that involves only the epidermis, the outer layer of the skin. It is characterized by reddening of the skin and perhaps some swelling. An example is a sunburn. Also called a first-degree burn.
rule of nines
a method used in calculating body surface area affected by burns
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. increase glucose demands. increase skeletal muscle breakdown. increase metabolic rate.
decrease catabolism. protein intake can decrease the protein losses by approximately 50%. A marked increase in metabolic rate is seen after a burn injury and interventions are instituted to decrease metabolic rate and catabolism.
client has received significant electrical burns in a workplace accident. What occurrence makes it difficult to assess internal burn damage in electrical burns? protein cell coagulation deep tissue cooling All options are correct. continuing inflammatory process
deep tissue cooling
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. What depth of burn injury does the client have? fourth degree superficial (first degree) superficial partial-thickness or deep partial-thickness (second degree) full thickness (third degree)
full thickness (third degree) Full-thickness (third degree) burn destroys all layers of the skin and consequently is painless. The tissue appearance varies and can be dry, pale white, red, brown, leathery, charred or lifeless.
escharotomy
removal of burn scar tissue
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? Rectal temperature of 100.4° F (38° C) White pulmonary secretions Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg Urine output of 20 ml/hour
Urine output of 20 ml/hour
deep partial thickness burn
extends into the skin dermis and the wound is red and dry, with white areas in deeper parts; can convert to a full-thickness burn if tissue damage increases with infection, hypoxia, or ischemia extends into the reticular layer of the dermis and is hard to distinguish from a full-thickness burn. It is red or white, mottled, and can be moist or fairly dry.
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. 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. 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. To cool wound and burning process
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. protecting the bed linens and client's clothing from contact to prevent staining. monitoring the client's Na+ and K+ serum levels and replace as prescribed. monitoring the client for the development of respiratory acidosis.
premedicating the client with an analgesic prior to application.
Which antimicrobials is not commonly used to treat burns? mafenide (Sulfamylon) tetracycline silver sulfadiazine (Silvadene) silver nitrate (AgNO3) 0.5% solution
tetracycline
Burn shock
third spacing" of fluid, severe hypovolemia, and decreased cardiac output (CO). Progressive edema develops in unburned tissue and organs, causing hypoperfusion and hypovolemic shock. As fluid loss continues and vascular volume decreases, the CO and BP falls.
A nurse is aware that after a burn injury and respiratory difficulties have been managed, the next most urgent need is to: Measure hourly urinary output. Replace lost fluids and electrolytes. Monitor cardiac status. Prevent renal shutdown.
Replace lost fluids and electrolytes.
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 is conscious. The client's breathing is unlabored and skin is clammy. The client's heart rate is rapid. The client's urinary output is 0.5 mL/kg/hour.
The client's urinary output is 0.5 mL/kg/hour.
