Burn Questions

The client is undergoing radiation therapy to treat lung cancer. Following the treatment, the nurse notes erythema on the client's chest and neck, and the client is complaining of pain at the radiation site. The nurse interprets this assessment data as: a. A superficial injury to tissue from the radiation. b. An allergic reaction to the radiation. c. A cutaneous reaction to products formed by the lysis of the neoplastic cells. d. An ischemic injury, much like decubitus formation, caused by pressure from the linear accelerator.

a. A superficial injury to tissue from radiation.

The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate which of the following signs in the client? a. Flushing b. Dizziness c. Tachycardia d. Coma

a. Flushing

The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. Which of the following would the nurse anticipate to be prescribed for the client? a. Immobilization of the affected leg b. Out of bed c. Placing the affected leg in a dependent position d. Bathroom privileges

a. Immobilization of the affected leg

The client sustained a burn from cutaneous exposure to lye. At the site of injury, copious irrigation to the site was performed for one hour. On admission to the ED, the nurse assesses the burn site and determines that the presence of which of the following indicates that the chemical burn process is continuing? a. Eschar b. Liquefaction necrosis c. Cherry red, firm tissue d. Intact blisters

b. Liquefaction necrosis

The nurse is administering fluids IV as prescribed to a client who sustained second- and third-degree burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which of the following would provide the most reliable indicator for determining the adequacy? a. Vital signs b. Urine output c. Peripheral pulses d. Mental status

b. Urine output

The client arrives at the ER following a burn injury that occurred in the basement at home. An inhalation injury is suspected. Which of the following would the nurse anticipate to be prescribed for the client? a. 100% oxygen via an aerosol mask. b. Oxygen via nasal cannula at 15 L/min. c. 100% oxygen via a tight-fitting, non-rebreather face mask. d. Oxygen via nasal cannula at 10 L/min.

c. 100% oxygen via a tight-fighting non-rebreather face mask.

The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that the anticipated therapeutic outcome of the escharotomy is: a. Brisk bleeding from the site. b. Formation of granulation tissue. c. Decreasing edema formation. d. Return of distal pulses.

d. Return of distal pulses.

The client was burned at 0700. The client states that before the burn, the body weight was 198 lb. The physician has estimated that the TBSA burned is 83%. Using the Parkland formula, the nurse determines that the total amount of IV LR solution that the client will receive by 1500 of the same day that the burn occurred is which of the following? a. 3735 mL b. 7470 mL c. 14,940 mL d. 29,880 mL

c. 14,940 90 kg X 83% X 4 mL = 29,880 mL/day 29,880/2 = 14,940 mL in the first 8 hours

The nurse is caring for a client who sustained second- and third-degree burns on the anterior lower legs and anterior thorax. Which of the following does the nurse expect to note during the emergent phase of the burn injury? a. Decreased HR. b. Increased BP. c. Elevated hematocrit levels. d. Increased urinary output.

c. Elevated hematocrit levels.

The burn client is receiving treatments of topical mafenide (Sulfamylon) to the site of injury. The nurse monitors the client, knowing that which of the following indicates that a systemic effect has occurred? a. Local pain at the burn site b. Local rash at the burn site c. Hyperventilation d. Elevated BP

c. Hyperventilation; mafenide can cause an acidotic state, so the body would compensate and try to blow the acid off by hyperventilating.

The nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which incorrect component of protective isolation technique? a. Using sterile sheets and linens b. Performing strict handwashing technique c. Wearing gloves and a gown only when giving direct care to the client. d. Wearing protective garb, including mask, gloves, cap, shoe covers, scrub clothes, and plastic aprons

c. Wearing gloves and a gown only when giving direct care to the client.

Mafenide (Sulfamylon) is prescribed for the client with a burn injury. When applying the medication, the client complains of local discomfort and burning. Which of the following is the most appropriate nursing action? a. DC the med. b. Notify the physician. c. Apply a thinner film than prescribed to the burn site. d. Inform the client that this is normal.

d. Inform the client that this is normal.

A two-year-old child is admitted to a burn unit with partial- and full-thickness burns over 35% of the body. After admission assessment review of the physician's orders, the priority nursing intervention focuses on: a. Sedating with morphine sulfate. b. Restricting IV administered fluids. c. Inserting a NG tube. d. Inserting a foley catheter.

d. Inserting a foley catheter.

The nurse is monitoring a child with burns during the treatment for burn shock. The nurse understands that which of the following assessments provides the most accurate guide for determining the adequacy of fluid resuscitation? a. Skin turgor. b. Level of edema at burn site. c. Adequacy of peripheral pulses. d. Neurological assessment.

d. Neurological assessment.

A 10-kg child sustains a burn from a house fire, and the TBSA of the burn is determined to be 50%. The Parkland formula for fluid resuscitation is used to determine the amount of fluid that this child requires. A nurse determines that the child will receive how many milliliters of fluid in the first 8 hours from the time of injury?

1000 mL 4 mL X 10 kg X 50% = 2,000 mL/day 2,000 mL/2 = 1,000 mL in the first 8 hours

The adult client was burned as a result of an explosion. The burn initially affected the client's anterior half of the head, the upper half of the anterior torso, and there were circumferential burns to the lower half of both of the arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head, and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury?

36% 4.5 + 9 + 9 + 4.5 +9 = 36%